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u 



MEDICAL AND SURGICAL 



LECTURES ON THE 



DISEASES OF WOMEN, 



CLINICAL AND SYSTEMATIC TKEATISE. 



R. LUDLAM, M. D., 

Professob of the Medical and Surgical Diseases of Women in Tfl.& Hahnemann 
Medical College and Hospital, of Chicago; Late President of the Amer- 
ican Institute of Homeopathy, and of the Chicago Academy of Medi- 
cine; Corresponding Member of the Homeopathic Medical 
Societies of Great Britain, France, Massachusetts, and 
New York; Author of a Volume of Clinical Lect- 
ures on Diphthebia; Membeb of the State 
Boabd of Health of Illinois, 

^ ETC., ETC. 



LECTUBES DELIYEKED FKOM 1870 TO 1887. 



sixth edition; revised, enlarged and illustrated. 



'JAN 301888 7 

CHICAGO: 

HALSEY BROTHERS, 

i 1888. 







k~\ 



Entered according to Act of Congress, in the year 1888, by 

HALSEY BROTHERS, 
in the office of the Librarian of Congress, at Washington. 



PEESS OF 

J. L. REGAN PRINTING CO., 

CHICAGO. 



PREFACE TO THE SIXTH EDITION. 



For more than a year past the fifth edition of this work has been 
out of print. It therefore became incumbent upon the author to 
revise and to correct it, to withdraw a portion of its old matter and 
to substitute new paragraphs and new lectures to the end that it 
might be in every way more complete and satisfactory than before. 

In the present edition the briefer articles and the new cuts have 
been interspersed through the volume wherever they were needed 
to modernize it and the better to illustrate the text. Many new 
cases have been added and the clinical character of the work has 
been preserved throughout. 

Of the new lectures that were not included in former editions 
there are, beside the Introductory Lecture, two upon the Path- 
ology of Ovarian Tumors; one on Explorative Laparotomy and 
Tapping; one upon Ovariotomy; one on the After Treatment and 
the Results of Ovariotomy, and one upon the Diseases of the Uter- 
ine Appendages, including the Battey-Tait operation. The surgi- 
cal treatment of Lacerations of the Perineum and of the Uterine 
Cervix, and also of Uterine Cancer have been reconsidered and 
treated of in the light of increased hospital and special experience. 

The text, which is closely printed and compact, does not discuss 
those theoretical and historical questions which are better suited 
for separate monographs, or for an encyclopaedia, and which man- 
ifestly are out of place at the bedside or in the clinical amphithe- 
atre. All this literary baggage, with which gynecology is being 
encumbered, is laid aside for what is more direct, important and 
useful. The result is submitted with a sincere regret that, even 
in its amended form, the work is not more perfect and complete; 

3 



4 PKEFACE TO THE SIXTH EDITION. 

but also with the hope that it may continue to be as useful and as 
acceptable in the future as it has been in the past. 

The thanks of the author are again due to Dr. Belle L. Reynolds, 
who for the past eight years has been his faithful assistant in the 
practice of this specialty, for the careful supervision of the work 
as it passed through the press. 

New Years, Chicago, 1888, 

1823 Michigan Avenue. 



CONTENTS. 



INTRODUCTORY LECTURE. 

LECTURE I. 

THE SEVEN CRITICAL PERIODS IN THE LIFE OF WOMAN. 

GENERAL PATHOLOGY. 

PAGE. 

1. Puberty 35 

Childhood— Girlhood— Womanhood— Clinical history of— Com- 
paiative risks of— Not identical with nubility — Early marriage 
and ; delayed. 

2. Menstruation 40 

Causes of suffering in— Three steps in— Influence of diathesis 
upon— Ditto of travel— Ditto of the hsemorrhagic tendency- 
Effect of intercurrent disease upon — Ditto of the cachexias— 
Ditto of mal- treatment— The menstrual cachexia. 

LECTURE II. 

general pathology— continued. 

3. Pregnancy - 45 

The physiology of— The diseases that are caused by— Relation of, 
to uterine displacements— Ditto to cervicitis— The common dis- 
eases of pregnancy— Changes of the blood in— Ditto of the heart 
—Rheumatism in — Ditto nervous affections — Ditto metro-cere- 
bral disorders — Ditto pulmonary — Digestive and urinary de- 
rangements—The diseases that are cured by pregnancy — The vis 
medicatrix of— Diseases that co-exist w tli pregnancy— Ovarian 
and fibroid tumors, etc. 

LECTURE III. 

general pathology— continued. 

4. Parturition 55 

Effects of, on the nervous sy-tem— In primiparse; ditto on mul- 
tiparas— Traumatic lesions of. 

•5. PUERPERALITY ' . . . . 57 



Diseases ol— Uterine involution, results if defective— Laceration 

5 



O CONTENTS. 

PAGE, 

of the cervix as a cause of post-puerperal diseases— The ca- 
chexia. 

6. Lactation 60 

A necessary condition of uterine retraction, and a natural pro- 
phylactic of post-puerperal disease — Effects of non-lactation in 
abortion— Why nursing is prophylactic of uterine disease — 
Weaning may be either harmful or salutary -Effects of undue 
lactation. 

7. The Climacteric .... 65 

The diseases of, are plethoric, anaemic, or nervous— The class of 
affections that are caused by this crisis, those that are cured by it 
and those that co-exist with. Post- climacteric affections. 

LECTURE IV. 

physical diagnosis in gynaecology. 

1. Inspection 66 

The four varieties of— Abdominal do. of the external parts ; 
ditto by the uterine speculum ; ditto by the forcible eversion of 
the rectum. 

2. Mensuration ... ....... 74 

Modes of applying. 

3. Palpation 75 

Abdominal and vaginal— Cases to which the former is applicable 
— The t; touch " per vagmam— Conjoined manipulation and when 
it is of use— The uterine " touch " and the conditions requiring 
it. 

LECTURE V. 

PHYSICAL DIAGNOSIS— CONTINUED. 

Physical Diagnosis 7S 

The three kinds of rectal touch— Manual exploration of the rec- 
tum, or Simon's method— The kt touch" by the bladder— The 
touch by the sound, why and when it should be employed — Di- 
rections as to time and mode of its introduction— The position 
of the patient— The conjoined use of the speculum and the 
sound— A rare Case — Sims' elevator as a sound. The sound in 
fibromata ; ditto instead of the tenaculum. 

4. Percussion 95 

Object, and range, and use of, in pregnancy, in ascites, ovarian 
dropsy, and uterine tumors. 

5. Auscultation . . . 96* 

Use and range of, cases to which it is adapted. 



CONTENTS. 



LECTURE VI. 

PAGE. 
CHLOROSIS 97 

Digestive, cerebral h,nd cardiac symptoms— Scrofulous ditto- 
Blood changes in— The nervous symptoms— The pulse, the appe- 
tite, menstrual derangements, the skin— Etiology of— Diagnosis 
of, from jaundice and anaemia— Prognosis— Treatment for the 
general and emotional causes— The cachexia, 2ron in— The citrate 
of iron and strychnia in— Special indication© for remedies— The 
diet — Exercise and travel. 



LECTURE VII. 

AMENORRHEA. 
3. 2>EL^YE.l> MENSTRUATION 13 

Etiology or— symptoms of— diagnosis, prognosis, and tt >tment. 

2. Suppressed Menstruation .'.."'. . . . , . .117 

Etiology— Symptoms, diagnosis, and treatment— Special indica- 
tions for remedies. 

3. Retention of the Menses . . 128 

Etiology, symptoms, diagnosis, prognosis, and treatment, both 
medical and surgical. 

LECTURE VIII. 

amenorrhea— continued . 

Amenorrhcea, with Prolapsus Uteri and Obstinate Vomit- 
ing • . , 132 

Resembling perforating ulcer of the stomach— Reposition of the 
uterus— Subsequent history— Note. 

Amenorrhcea with Choreic Spasms 138 

Remote disease from an arrest of the menses — Forcing the flow 
— Effect of rest and quiet. 

Amenorrhcea with Supra-Orbital Neuralgia . . . 143 

Varieties of menstrual neuralgia— Local and Specific treat- 
ment. 

Jpinal Irritation, with Amenorrhcea, Vicarious Vomiting, 

etc 144 

Convulsions— Causes of— Theories in— Treatment— Subsequent 
history. 

Amenorrhcea in Advanced Phthisis '. 149 

Remedies and prognosis. 



CONTENTS. 



LECTURE IX. 
Menstrual Headache . .151 

Often overlooked— From uterine deviations— Ovulation and 

cephalalgia— Diagnosis— Prognosis— Treatment. 
Menstrual Retention a Cause of Uterine Displacements . 160 

May become chronic— Treatment. 
Uterine Colic .."... 164 

Cause— Symptoms— Palliatives— Internal remedies. 

LECTURE X. 

Menstrual Epilepsy 168 

Uterine and ovarian epilepsy— From amenorrhcea— Inter-men- 
strual epilepsy— Epilepsy after dysmenorrhea— Sequela?, and 
non- sexual causes of— Prognosis— Treatment. 

Irregular Menstruation with Epileptiform Hysteria . 175 
A compound affection— The two distinctive stages of the fit- 
Diagnosis— Prognosis and treatment. 

Too Frequent Menstruation in Incipient Phthisis . . 179 
Menstruation and tuberculosis— Menorrhagia and ditto— Signifi- 
cance of the aphonia— Treatment, remedies, season and cli- 
mate—Mental worry. 

LECTURE XL 

Dysmenorrhea ,183 

Definition and varieties— Causes— Symptoms, complications, 
sequels— Diagnosis— Prognosis— Surgical treatment. 

Obstructive Dysmenorrhea from Post-Puerperal Atresia 197 
Dates from puerperalitv— The result of adhesive inflammation 
and stenosis— A clinical lesson — A contra-indication for anaes- 
thetics— The use of the uterine stem. 

LECTURE XII. 

Obstructive Dysmenorrhea from Stenosis of the Uterine 
Cervix and Pelvi-Peritonitis . . . . . . .201 

Rule for operations on the cervix— Post-surgical peritonitis. 
Obstructive Dysmenorrhea from Retroflexion of the 

Uterus 202 

Causes— Symptoms— Diagnosis— Sequelae and treatment. 

Neuralgic Dysmenorrhea .210 

The importance of physical signs— A neurosis— Symptoms- 
Relation of the flow to the degree of pain— Treatment. 



CONTENTS. 9 

s PAGE, 

Spasmodic Dysmenorrhea 215 

Effects of stimulants— Ditto of opiates— Medicinal aggravations 
— Gelsemium and other remedies. 

LECTURE XIII. 

Membranous Dysmenorrhcea 219 

Causes, anatomical peculiarities of the membrane, its clinical 
confirmation— Shape and size of the membrane— Its expulsion- 
Practical deductions— Diagnosis from abortion— Special thera- 
peutics—Other expedients— The sponge tent. 

LECTURE XIV. 

Membranous Dysmenorrhcea from Repelled Eruptions . 234 
Treatment— Sterility as a sequel. 

Borax in Membranous Dysmenorrhea . . . .241 

Treatment. 

Membranous Dysmenorrhcea from Exfoliative Endometritis 243 
Rarity of this form— Pessaries in— Version as a factor in— Pecu- 
liar remedies in. 

Ovarian Membranous Dysmenorrhcea . . . . . 245 

The button-hole os uteri— Oldham's theory illustrated— Gel- 
semium the remedy. 

LECTURE XV. 

Menorrhagia 247 

Definition of— Differential diagnosis— Remedies— Surgical treat- 
ment. 

Nitric acid in Menorrhagia 252 

Metrorrhagia after abortion— Clinical deductions— Post-dysmen- 
orrhoeal haemorrhage— Haemorrhage at the climacteric— Practi- 
cal conclusions. 

Menorrhcea— Cervical Epistaxis 255 

Its relation to menstruation— A diagnostic rule— A physiologi- 
cal reason— Peculiarity of the flow— Its critical nature— Neces- 
sity of physical examination— Sterility from— Medicine versus 
Surgery— Not to be confounded with unavoidable haemorrhage 
—General therapeutics— The different cachexiae— Nitric acid. 

Menorrhagia with Remittent Eever 262 

Complication with malarial fever— Uterine disorders not always 
easy of cure. 
Menorrhagia with Rheumatism 263 



10 CONTENTS. 

LECTURE XVI. 

^ PAGE 

Menorrhagia— Continued 263 

Menorrhagia with hemiplegia — Menorrhagia from a uterine 
libroid. 

Menorrhagia with Convulsions . . ... . . .265 

Sudden Suppression of Menorrhagia by Astringents the 

Cause of Subsequent Illness 271 

Menorrhagia sometimes critical— Digestive disorders from vag- 
inal and uterine injections— Menorrhagia from polypi. 

Vicarious Menstruation 275 

Treatment. 

LECTURE XVII. 

The Differential Diagnosis of Pregnancy .... 279 

False conception— Molar pregnancy— Morbid anatomy of— Prob- 
able signs of pregnancy. 

Excessive Abdominal Development in Pregnancy . . 287 

Diagnosis— Prognosis— Treatment— Pulsatilla in mal -presenta- 
tions. 

LECTURE XVIII. 

Bilious Colic During Pregnancy ....... 293 

Treatment— Local palliatives— Prophylaxis— Diet— Mental and 
physical exercise. 

Albuminuria in Pregnancy 297 

Signs of convulsibility— Mercurius cor. in— No infallible pro- 
phylactic for convulsibility. 

Abdominal Cramps and Pains in Pregnancy . . . . 2°9 

Diagnosis— Spurious peritonitis— Diagnosis from cutaneous neu- 
ralgia, uterine colic— Prognosis— Treatment — Remedies. 

The Nausea and Vomiting of Pregnancy .... 304 

May occur at any period of pregnancy— Significance of a coinci- 
dent jaundice— Treatment— Special indications for remedies- 
Stretching the cervix— The expediency of abortion— Dangers 
from hepatic and urinary complications— Varicose veins. 

LECTURE XIX. 

Morning Sickness of Pregnancy and Retro- version . . 311 
Morning sickness may be salutary— The prognosis of inevitable 
abortion, unwarranted— Treatment — How to replace the womb 
if retro-verted — The uterine sound — The indication for a pes- 
sary— Tyler Smith's case. 



CONTENTS. 11 

PAGE. 

Chorea during Pregnancy ........ 318 

Etiology— Nature — Anaemia — Symptoms — Localized chorea — 
Prognosis— The fatal form— Treatment— Remedies. 

LECTURE XX. 

Abortion with. Misplaced P^ins 326 

The habit of aborting — Intermittent abortion — Treatment— 
Gelsemium in. 

The Sequelae of Abortion . 329 

Causes of aborting — Quickening not the first sign of life— Dis- 
ease that may follow— Differential diagnosis between spontan- 
eous and induced abortion— Treatment— Remedies. 

LECTURE XXI. 

Stomatitis Materna.. Nursing sore Mouth .... 339 

Nature — Peculiarities— A constitutional disease — Reaal and 
vesical symptoms— The anaemia— Diagnosis— Prognosis — Treat- 
ment—Expedients for arresting the disease— Weaning the child 
—Indications for arsenicum alb , mercurius sol., calcarea carb., 
etc. — Local treatment. 

LECTURE XXII. 

Sub-involution of the Uterus 353 

Etiology— Treatment— The physiological action of ergo!— Indi- 
cations for secale, china, etc, 

SUB-INVOLUTION AND RECURRENT ABORTION . . . .361 

Types of abortion— Peculiar cause of— Treatment — Peculiar sus- 
ceptibility—Remedies. 

sub-involution and chronic metritis of eighteen years 

Standing . 364 

Causation— Physical signs. 

Sub-involution, Chronic Metritis, Menorrhagia and Pro- 
lapsus , . 365 

A practical lesson. 

LECTURE XXIII. 

Pelvi-peritonitis .... 367 

Clinical history— Varieties— Symptoms- -Temperature and pulse 
—Three points to be observed in local examination— The peri- 
toneal tumor— Reflex, digestive, and other disorders— Causes— 
—Diagnosis— Prognosis — Treatment — A substitute for opium in 



12 CONTENTS. 

PAGE. 

—Remedies— Macrotin— Pel vi-peritonitis, prolapsus, with um- 
bilical hernia — Pelvi-peritonitis with partial stenosis of cervix 
uteri— Pelvi-peritonitis and laceration of cervix. 



LECTURE XXIV. 

Pelvic Cellulitis, Pelvic Abscess ♦ . 385 

Synonyms— The four stages of — First, or congestive— Second — 
or stage of effusion — Third, or that of resolution— Fourth, or 
suppurative— Seat of the fluctuation— Diagnosis of the presence 
of pus— Essential nature of pelvic cellulitis— Is probably allied 
to erysipelas— Causes— A contingent 10 uterine surgery— Diag- 
nosis— Sequelse— Prognosis. 

LECTURE XXV. 

Pelvic Cellulitis Continued 399 

Qualifying conditions— (1) The cause— (2) The complicating 
lesions— (3) The condition of the menstrual function— (4) The 
treatment to which the patient has been subjected— (5) Her 
puerperal experience— (6) The dyscrasia upon which the cellu- 
litis has been engrafted— Pelvic cellulitis with intestinal fistulae 
Pelvic cellulitis with abscess, following delivery— Treatment- 
General indications for remedies— Stimulants— To promote sup- 
puration —After-treatment. 

LECTURE XXVI. 

Pelvic Hematocele 418 

Definition and clinical history— Etiology— The hemorrhagic dia- 
thesis— Pachy-peritonitis— From cervical stenosis— Source of the 
haemorrhage — Symptoms— Signs per vaginam — Voisin's descrip- 
tion of the formation of the tumor — General symptoms— The 
pain— The anaemia— Diagnosis— Pelvic hsematocele and extra- 
uterine pregnancy— The aspirator and exploring needle in— 
Prognosis— Medical treatment— Surgical treatment— Tapping. 

LECTURE XVII. 

Cervical Metritis .... ..... 437 

Acute cervical metritis— Varieties of— Differential diagnosis 
Prognosis— Treatment— The hot rectal douche. 

Chronic Corporeal Cervicitis 443 

Symptoms— Menstrual disorders— Nature and cause— Diagnosis 
Prognosis — Treatment — General indications for treatment — 
Remedies. 



CONTENTS. 13 

PAGE. 

Corporeal Cervicitis and Scanty Menstruation . . 447 

Query— Treatment— Tartar emetic- -The sponge tent as a means 
of diagnosis. 

LECTURE XXVIII. 

Chronic Cervical Endo-metritis, Uterine Leucorrhcea . 451 
A glandular lesion— Cervical leucorrhoea is not uterine catarrh 
— A sequel of labor — The scrofulous cachexia a predisponent — 
Tuberculosis a predisponent — Biliary disorders an exciting 
cause— The exciting causes — Symptoms — The leucorrhcea a 
symptom— Pelvic pains and suffering— Constitutional effects- 
Examination by the speculum— Diagnosis — Prognosis— Treat- 
ment— Remove the cause— Necessity for a good diet— The top- 
ical use of glycerine, calendula and hydrastis— Pessaries are 
contra-indicated— Escharotics— Natural secretions and abnor- 
mal discharges— Remedies for reflex ovarian disease — Ditto for 
various symptoms and groups of symptoms. 

LECTURE XXIX. 

Abscess of the Mammary Gland 471 

Treatment— A domestic expedient— The knife— A good diet ad- 
visable. 

On Weaning a Child .and the Subsequent Treatment of 

the Mammary Glands 474 

111 effects of too prolonged lactation— The proper time for wean- 
ing— Treatment— An tigalactics— Local applications. 

Excoriated Nipples 480 

Most frequent in primiparae— Symptoms— The excoriation— The 
ulceration— Treatment— Prophylactics— Applications for various 
conditions— Precautions— Remedies. 

LECTURE XXX. 

Recurrrent Abortion from Mal-lactation .... 487 
Leucorrhcea. the Cause of Impaired Lacteal Secretion . 489 
Leucorrhcea and scrof ulosis— Illness of the child and leucorrhcea 
of the mother— Uterine leucorrhoea and sterility— Treatment- 
Weaning the child— A proper diet— Lymphatic stimulants. 

Loss of Nipples from Erysipelatous Inflammation . . 494 
Belladonna— Glass nipple-shields. 

Anemia from Conjoined Lactation and Menstruation . 495 

Unilateral Neuralgia from Prolonged Lactation . . 496 

Extraordinary Lactation .497 



14 CONTENTS. 



LECTURE XXXI. 

„, PAGE. 

The Menopause 499 

Duration of menstrual life — Importance of the change— Diseases 
incident to puberty may return— Symptoms— Haemorrhage at— 
Alimentary symptoms— Nervous symptoms— Epilepsy— Disor- 
ders of the generative system— Prognosis— Treatment— Reme- 
dies 

The Comparative Frequency of Various Diseases at the 

Climacteric .509 

Skin Diseases and Hysteria at the Climacteric . . . .511 
Treatment— Character of the eruption may indicate the remedy 
—Hysteria incident to menstrual life— Treatment. 



LECTURE XXXII. 

Incipient Paralysis ai the Climacteric 517 

Critical disease may precede the arrest— Significance of the dis- 
charge at the change— Remedies for the acrid flow. 

Post-Climacteric Neurosis ......... 520 

Climacteric Rheumatism 520 

Remedies for. 
Bilious Colic at the Climacteric ....... 522 

Chamomilla. 
Prolapsus Uteri with Dropsy, at the Climacteric . . . 523 

Parturition a cause of uterine deviation— Treatment— Internal 

remedies. 

Post-Climacteric Anasarca 525 

LECTURE XXXIII. 

Affections of the external Generative Organs . . .527 

Pruritus of the vulva— Various causes of — Pruritus with dys- 
menorrhea and amenorrhoea— Pruritus at the climacteric— Pru- 
ritus during pregnancy— Prognosis— Treatment— Remedies. 

Abscess of the Labia Majora and of the Vulvo- Vaginal 

Glands 534 

Special pathology of— Symptoms— Diagnosis. 

Eczema of the Vulva 538 

Vulvo- Vaginitis, Prurigenous Vulvitis 538 

Symptoms— The eruption— Causes— Diagnosis— From granular 
vaginitis— Erom follicular vulvitis— Prognosis— Treatment. 



CONTENTS. 15 

PAGE. 

Infantile Leucorrh^ea ... » 543 

Causes— Treatment— Isolation . 

LECTURE XXXIV. 

Vascular Tumor of the Meatus Urinarius 546 

Nature and location— Symptoms— Necessity for physical exam- 
ination—Treatment—Excision—A new mode of operating- 
After-treatment. 

Non-Specific Urethritis . . 551 

Causes— Symptoms— Character of the urine— Diagnosis from 
stone— From gonorrhoea— From cystitis— Treatment. 

Urethral Fever, and Fissure of the Urethra . . . .557 
Pathology of— Treatment— For the vesical and renal complica- 
tion, and for the laceration of the urethra. 

LECTURE XXXV. 

Cystocele — Hernia of the Bladder,— Vaginal Cystocele . 560 
Cystocele— Symptoms— Varieties— Signs of— Treatment— Opera- 
tions for cystocele and rectocele. 

Dilatation of the Urethra as a Means of Diagnosis in Dis- 
eases of the Bladder and Urethra in Women . . 565 
The sponge tent in urethritis— Vesical inspection and palpation 
— Intra-vesical inspection and palpation. 

Hysterical Ischuria 571 

Varieties of— Physiological complications in— The secondary 
form— Internal remedies. 

LECTURE XXXVI. 

Cystitis 575 

Causes— Symptoms— Diagnosis— Treatment local, general, surgi- 
cal and dietetic— Washing out the bladder— Re medies for— 
Cystotomy— Mode of performing, the after-treatment— Objec- 
tions to, results of, the artificial eversion of the bladder, drain- 
age—The milk diet in— The Clysmic spring water in. 

The Irritable Bladder 584 

Causes of — Hysteria as a factor in— Three points in the diagnosis 
of— Treatment. 

Stone in the Bladder and in the Urethra 585 

Relative frequency of in women— Causes— Symptoms— Prognosis 
—Lithotripsy and vaginal cystotomy— Supra-pubic lithotomy— 
Spontaneous discharge of a calculus weighing thirty-six and 
one-half grains. 



16 CONTENTS. 

LECTURE XXXVII. 

PAGE, 

Uterine Deviations and Displacements 589 

General considerations upon— The natural position and mobility 
of the uterus— The uterine ligaments and the cellular tissue as 
a means of support— The etiology of uterine displacements— 
The predisposing, and avoidable causes of— The intrinsic, extrin- 
sic, and accidental ditto— Symptoms of — Diagnosis— Treatment 
The scope and value of internal remedies exclusivei/— Cardinal 
symptoms in the choice of a remedy —The use and abuse of pes- 
saries — Reasons for objections to them — Harmful varieties of— 
Contra-indications for— Indications for— Abdominal belts and 
supporters— Dr. Hodge's experience with them. 

LECTURE XXXVIII. 

Prolapsus Uteri and Procidentia 602 

Pseudo-prolapse of the uterus — Consequences of incorrect diag- 
nosis — VVhat remedies may do in prolapsus. 

Prolapsus Uteri, with Superficial Ulceration of the Cer- 
vix .-....- 605 

Irregular menstruation a cause of prolapsus — Prolapsus and 
paralysis— Hysterical complications — Cause of uterine abrasion 
—Uterine ulceration and abrasion— Treatment— Corxtsa- indica- 
tions for the pessary— Local expedients. 

Prolapsus Uteri with Right Latero- version . . . 612 

Latero-version from an over-loaded rectum — Treatment. 

Prolapsus with Anterior Inclination of the Fundus Uteri 616 

Procidentia Uteri 616 

Elytronhaphy for— Episio-perineorrhaphy for. 

Procidentia Uteri from Pertussis . . . . . . 619 

Cough a cause of uterine displacement— Labor a predisponent 



-Treatment. 



LECTURE XXXIX. 



Flexions and Versions of the Uterus 622 

General remarks upon flexions— Varieties— Retro-flexion— Diag- 
nosis— The uterine sound and the touch in— Re-position of the 
organ— Stem pessaries— Ante-flexion— Comparative frequency of 
—Causes, diagnosis, and treatment— Latero- flexion — Causes- 
Symptoms— Contingent affections— Postural treatment. 

Versions of the Uterus . . . . . . ... .633 

General remarks— Varieties— Retro-version of the uterus— Symp- 



CONTENTS. 17 

PAGE. 

toms— Diagnosis — Treatment— Pessaries in — Internal remedies 
—Ante- version of the uterus— Symptoms— Diagnosis— Treatment 
Latero-version of the uterus— Peculiarities of— Physical signs of 
— Treatment. 

Inversion of the Uterus 641 

Causes— Symptoms— Form of the tumor in — Diagnosis— The 
crucial test for— Prognosis— Treatment in recent cases— Manual 
treatment for the reduction of— Tate's vesico-rectal method— 
Courty's rectal method— Emmet's expedient— Sims' and Barnes' 
method— White's operation— Thomas' method of replacing — 
Amputation a dernier ressort. 

LECTURE XL. 

Ulceration of the Womb 649 

General observations on uterine ulceration— Varieties of. 
Simple Ulcer of the Uterine Cervix 650 

Subjective symptoms— Causes— Treatment. 
Apthous Ulceration of the Os and Cervix Uteri . . 653 

The eruptive stage— Symptoms— Diagnosis— Causes— Treatment 

Reprehensible practice— Remedies for the various stages. 

Irritable Ulcer of the Uterine Cervix . . . .658 

Reflex relations of uterus and stomach — The speculum not 
always needed— Appearance of the ulcer— Treatment— Cure the 
indigestion— Internal remedies— Local treatment. 

Diphtheritic Ulceration of the Os Uteri. . . . .663 

Constitutional symptoms — Physical symptoms— A secondary 
disease— Cause— Treatment, local and medicinal. 

POST-FARTUM ULCERATION OF THE WOMB 665 

Likely to be overlooked— Due to an impaired quality of the 
blood— Weaning the child— The diet— Exercise— Indiscriminate 
and exclusive local treatment— Arguments pro and con— Inter- 
nal remedies. 

LECTURE XLI. 

LEUCORRHCEA WITH CHRONIC OVARITIS ...... 671 

General remarks on leucorrhoea— Reflex relations of the ovary 
Sympathy between the uterine cervix and the ovaries— Leucor- 
rhoea may substitute menstruation— Uterine and vaginal catarrh 
from ovaritis— Sterility from— Treatment. 

Chronic Leucorrhcea and the Scrofulous Dyscrasia . . 676 
Leucorrhoea may be critical— Local and general causes— Consti- 
tutional causes— Scrofulosis in— Treatment— Remedies. 



18 CONTENTS. 

PAGE. 

Irritable Uterus— Rysteralgia 681 

Has no definite lesion— Limited to menstrual life— Predisposing 
causes — Exciting causes— Symptoms — Diagnosis — Treatment 
Surgery contra-indicated— Remedies. 



LECTURE XLII. 

Uterine Cancer 692 

General observations — Varieties — Causes — Symptoms — The 
haemorrhage— Diagnosis— Course and duration— The cancerous 
cachexia— The copraemia and cancerous complexion — Influence 
of pregnancy and labor upon — Prognosis — Carcinophobia — 
Causes of death from — Laceration of the cervix and uterine 
carcinoma— The local and medical treatment— Surgical treat- 
ment. 

LECTURE XLIII. 

Epithelioma of the Uterus ,708 

Epithelial cancer of the cervix uteri — Nature and clinical his- 
tory of— Pathological anatomy of— Symptoms— Development of 
the cachexia— Diagnosis — Prognosis— Treatment — Sims' opera- 
tion for— Remedies. 

LECTURE XLLV. 

Ovaritis ...... 724 

Synonyms— Causes; medical, mechanical, epidemic, traumatic- 
Symptoms— Prolapse of the ovary— Peritoneal ovaritis— Dysmen- 
orrhoea and menorrhagia in— Gonorrhceal do. 



LECTURE XLV. 

Ovaritis Continued ... 738 

Morbid anatomy of— Abscess in— Diagnosis— Prognosis— Seque- 
lae— Menstrual disorders— Sterility— Treatment— Ditto, of the 
puerperal form— Remedies in the common form— Local Reme- 
dies. 



LECTURE XL VI. 

Ovarian Neuralgia— Ovaralgia 757 

Etiology — Clinical history — Diagnosis — Prognosis — Treatment 
Remedies. 

Ovarian Irritation— Ovarian Dyspepsia ..... 768 
A pathognomonic sign— Excising causes— Remedies. 



CONTENTS. 19 



LECTURE XLVII. 

PACE. 

Hysteria „ ... 771 

Menstrual disorders in — Incongruous symptoms of — Malingering 
—Diagnosis from cardiac disease. Insanity, dropsy of the heart 
.and from pectoral disease— Hysterical aphonia— Dr. Chairon's 
pathognomonic sign of. 

LECTURE XL VIII. 

Hysteria, Continued . 785 

Hysteria complicating child-bed disorders, peritonitis, fevers, 
and hypocondriasis— May counterfeit labor— Diagnosis of from 
epilepsy— Nature— Prognosis— Treatment— Narcotics and anti- 
spasmodics. 

LECTURE XL1X. 

Treatment of Hysteria, Continued 804 

Treatment during the fit— Treatment for the hysterical diathesis 
Do. for the accompanying lesions and complications— The utero- 
gastric and utero-cardiac disorders— Neurasthenia. 

Hysterical Hemiplegia . • . . 810 

Hysterical mimicry— Diagnosis— Prognosis— Treatment— Reme- 
dies. 

LECTURE L. 

Spinal Irritation— Notalgia . S15 

Causes— Peculiar organization a predisponent— Of nervous origin 
—Symptoms, reflex and direct— Spinal irritation and uterine dis- 
ease — Diagnosis— Prognosis— Treatment. 

PHYS03IETRA 830 

Causes, diagnosis— Treatment. 

LECTURE LI. 

Uterine Surgery Versus Uterine Therapeutics . . . 835 
Scepticism respecting medication— Surgery more popular— Dis- 
advantages of the specialist— A great error— Surgery and thera- 
peutics—New provings by women a necessity— Study diagnosis 
and pathology— Pathogenesis and symptomatology. 

The Gynaecological Chair or Table .813 



20 CONTENTS. 

PAGE. 

Vaginismus ... 846 

Symptoms— Causes— Diagnosis— Medical and surgical treatment 
Tilts' and Sims' operation for— Local anaesthesia in acute cases. 



LECTURE LII. 

Laceration of the Cervix Uteri . ■ 855 

Discovery and description of— Clinical history— Causes— Symp- 
toms, subjective and objective— Varieties— Cervical ectropium 
Follicular degeneration— Cicatrization— Diagnosis — Complica- 
tions—Laceration with sub-involution— Epithelioma, peri-metri- 
tis, and sterility— Prognosis— Treatment, preventive, prepara- 
tory and operative— Trachelorrhaphy— The after-treatment. 

LECTURE LIU. 

Vesico- vaginal Fistula 870 

The varieties of vesical and vaginal fistulas— Vesico- vaqinal jis- 
tuloe— Causes, from child-birth, from wounds, calculi, syphilis, t 
cancer, etc.— Symptoms— Physical signs of— Prognosis— Treat- 
ment in recent and in chronic cases, by cauterization and Sims' 
operation. 

Recto-vaginal Fistula . 885 

Causes— Physical signs— Prognosis— Treatment by surgical pro- 
cedure. 



LECTURE LIV. 

Lacerations of the Vulva and of the Perineum — Peri- 
neorrhaphy 890 

These lacerations are often confounded— The anatomy of the 
vulvar orifice— Lacerations of the fourchette— Anatomy of the 
perineum— Varieties of perineal laceration — Frequency of do. 
—Symptoms— Treatment— The primary and secondary opera- 
tions. 

LECTURE LV. 

The Pathology of Ovarian Tumors 905 

1. Ovarian Cysts, morbid anatomy of — The ovarian cell — Symp- 
toms — Subjective signs in— Physical signs — 2. Dermoid Cysts of 
the ovary — Diagnosis— 3. Fibroid Tumors of the ovary — Laparo- 
tomy as a diagnostic resouree. 



CONTENTS. 21 



LECTURE LVL 

PAGE. 

The Pathology of Ovarian Tumors — Continued .... 918 
IV. Malignant Tumors op the Ovary — 1. Cysto-sarcoma; phys- 
ical signs and diagnosis — 2. Cysto-carcinoma — 3. Schirrhus of the 
ovary — 4. Colloid, or Myxoma — 5. Papilloma, Epithelioma and 
Cauliflower degeneration of the ovary — 6. Encephaloid of the ovary. 

LECTURE LVIL 

The Differential Diagnosis of Ovarian Dropsy ' . . . . 932 
1. From ascites — 2. From encysted peritoneal dropsy — 3. From 
pregnancy — 4. From extra-uterine pregnancy — 5. From uterine 
fibroids — 6. From fibro-cystic growths — 7. From physometra — 8. 
From distention and prolapse of the bladder — 9. From enlarge- 
ment and malignant diseases of the liver and spleen — 10. From 
tumors which are due to menstrual retention. — 11. From renal 
cysts and floating kidney. 

LECTURE LVIII. 

Explorative Methods of Diagnosis 945 

1. The Exploratory Incision— Mode of making — Suitable cases 
for — Practical value of. 

2. Tapping — Not curative — As a palliative — A dangerous and un- 
satisfactory expedient — Has fallen into disuse — Increases the risks 
of ovariotomy, etc. 



LECTURE LIX. 

Ovariotomy 960 

The early operation — Suitable cases for — Contra-indications for — 
Preparatory treatment — Asepsis and antiseptics— Surgical cleanli- 
ness—Assistants and instruments — Steps of the operation — Man- 
agement of the adhesions; do. of the haemorrhage; do. of the 
pedicle — The peritoneal toilet— The clamp and the objections to — 
Drainage — The sutures — First dressing of the wound — Putting the 
patient to bed. 

LECTURE LX. 

The After-Treatment 985 

The importance of — Shock and reaction — Special and accidental 
symptons — Diet and drinks— Remedies for the nausea and vomit- 



22 CONTENTS. 

PAGE. 

ing, tympanites and peritonitis— The urine, the condition of the 
bowels — Care of the drainage tube — Secondary haemorrhage— Re- 
opening the abdomen — Removal of the sutures — Contingent 
affections — Convalescence. 

The Results of Ovakiotomy 1000 

Causes of the comparatively low death-rate — General consider- 
ations upon. 

LECTURE LXI. 

Ovariotomy by Enucleation , 1003 

Miner's method of — Cases that are suitable for — Ludlam's method 
of enucleating an ovarian cyst — The stripping out of the lining 
membrane of an unilocular sac weighing thirty pounds — Appear- 
ance of the matrix — Absence of haemorrhage— Suppuration— Rad- 
ical recovery and mode of union of the divided surfaces. 

Ovariotomy by Partial, Enucleation 1009 1 

The details of a remarkable case in which a tumor weighing eighty 
pounds was removed by this process — The process by which the 
formidable adhesions are separated — The risks of the operation — 
The great necessity for care in making it, and the reasons for the 
exemption from haemorrhage. 

Vaginal Ovariotomy 1013 

Cases adapted for — Mode of operating — The after-treatment. 



LECTURE LXIL 

Diseases of the Uterine Appendages 1016 

Class of women who are subject to — From imperfect development, 
obstructive and membranous dysmenorrhoea, puerperal affections, 
scrofula and gonorrhoeal infection — Tubal and ovarian tuberculo- 
sis — Forms of ovarian degeneration — Varieties of salpingitis — Diag- 
nosis of— Fallopian colic— Signs of— Battey, Hegar and Tait's 
operations for— Oophorectomy and salpingotomy. 

LECTURE LXIII. 

Fibroid Tumors of the Uterus 1032 

Their relative frequency, patho ogical anatomy, number, weight, 
texture and varieties — 1. Sub-mucous fibroids — Symptoms— The 
haemorrhage, uterine deviations, the uterine souffle, tolerance of 
the tumor, bi-manual examination— Causes — Diagnosis from ovar- 



CONTENTS. 23 

PAGE. 

ian dropsy, pregnancy, hydatids, and uterine versions — Prognosis 
— Treatment, medical, palliative and surgical — 2. Sub-peritoneal 
fibroids — Symptoms — Coincident disorders — Diagnosis — Cause 
and termination — Treatment, medical and surgical — Hysterectomy. 

LECTURE LXIV. 

Fibroid Tumor op the Uterus — Continued ..... 1056 
Interstitial Fibroids — Symptoms — Dysmenorrhea — Menorrha- 
gia, abortion, sterility — Diagnosis— The tenaculum, the sound and 
dilatation — Treatment, medical and surgical — Trillin in monorr- 
hagia. 

Uterine Polypi 1064 

Pathology and treatment of. 



THE 

DISEASES OF WOMEN 



PART FIRST 



GENEEAL PATHOLOGY AND PHYSICAL DIAGNOSIS. 



INTRODUCTORY LECTURE* 



It affords me great pleasure, in returning from a foreign vaca- 
tion, to find that our Annual Course of lectures has been opened 
promptly and properly; that the Class is already at work; that the 
Hospital has been repaired and is re-occupied; and that everything 
connected with an institution in which I have already labored for 
a quarter of a century is what its best friends could desire. My 
congratulations are necessarily late, but they are none the less 
hearty; and I am ready, as I am certain that you are also, for the 
work that is before us. 

The authorities of this school, for whose judgment I have the 
highest respect, have thought best to limit my sphere of teaching 
almost entirely to the department of Clinical Gynecology. To this 
end, as you are aware, they have appointed Professor Bailey as my 
assistant, and have arranged that henceforth he shall give the 
largest share of the Theoretical course upon the Diseases of 
Women. The plan is practical; it has my hearty approval; and 
you will be the gainers thereby. 

I appear before you, therefore, in the simple and single capacity 
of a clinical teacher, a calling and a position which is second to 
none in importance, and one in which, if its occupant is competent 
and conscientious, the greatest possible good may be done. For 
clinical teaching is the highest type of medical training. It may 
be, and it often is undertaken by professors and pupils before 
either party is prepared for it, or before they have obtained a cor- 
rect and comprehensive idea of what is included in an objective, 
bed-side course upon practical medicine or surgery. 

* Delivered at the opening of the winter session for 188-1-5. 

24 



INTRODUCTORY LECTURE. 25 

Let us consider the object of the Women's Clinic in this college 
and hospital; for in taking a new start on the old road, there must 
be no mistake about putting the saddle on the right horse. The 
purposes of this clinic are so varied and so important that it may 
be well to study a few of them separately. 

I. The Proper Mode of Questioning our Patients. — In the 
outset I must remind you that the class of patients which will be 
brought before you in my clinic are in certain respects peculiar, 
and that your success in practicing your profession among women 
will depend in large measures upon your method of approaching 
and of questioning them when they are ill. The natural timidity 
of the sex; the results of the mal-education of our young women; 
the peculiarity of their nervous organization; the habit of suppress- 
ing the signs of suffering, that is so prevalent among women ; the 
hysterical tendency under certain conditions to exaggerate their 
ailments, or to antagonize and resent your opinions and enquiries ; 
the effects of a monthly martydom from which during middle life 
they are never wholly free; and the consequences of child-bearing, 
are so many obstacles to be overcome in the examination. Unless 
you respect and regard these conditions, your witness will not tes- 
tify to the facts in the case, and your advice as well as your repu- 
tation, will be thrown away T . 

How, then, shall we elicit the desired information? With such 
a list of modifying conditions, it is manifest that a stereotyped 
plan of putting our questions will not answer in all cases. Nor 
would it be prudent or proper always to begin with enquiring after 
the uterine or pelvic symptoms. The age, the marriage relation, 
the number of children, or of abortions or miscarriages, and an 
outline of the puerperal experience being noted, the way is clear 
for a direct examination. If by this time you have secured the 
patient's confidence, and if she is intelligent and clever, and so 
disposed, you may put a leading question or two and then permit 
her to tell her own story. Meanwhile you must listen with a calm, 
judicial temper; for the evidence must fall upon a mind that k 
capable of sifting it, and of selecting those points which are of real 
practical interest to the exclusion of everything else, or you will 
have gained nothing by the examination. 

If you will cultivate the temper to which I refer it will keep you 
from pre-judging the nature of the case in hand, and also from 
prescribing prematurely. Nothing is more weak and unsatisfac- 
tory than the trick of putting questions to an emotional witness 
in such a way as to make her testify to just what you want to elicit. 
If I should undertake to prove to you, by questions and answers 
only, that a hysterical woman has ovaritis, my questions might be 
so framed as to fashion her sensations for her, and to make her 
feel in imagination just as she would if she were really ill with it. 
And so also, if I ask such an one whether she has this or that 
symptom, or class of symptoms, (which I may carry in my mind 



26 



INTRODUCTORY LECTURE. 



as the picture of a drug proving), her statements may be warped 
by my question, which is really more of a suggestion than an 
enquiry. This kind of subornation of medical witnesses is, I am 
sorry to say, far more common than is generally supposed. It so 
often constitutes a species of self-deception on the part of the doc- 
tor, as well as of the patient, that you will need to guard against 
it, and more especially in your gynecological practice. 

The older writers used to distinguish between the signs and the 
symptoms of disease, and it might be well for you to bear this 
distinction in mind. A sign of disease was something positive 
and unmistakable, if not absolutely pathognomonic; while a symp- 
tom was inconstant, uncertain, common to functional disorders 
especially, and not always serious or significant. If we except the 
case of a small share of hysterical, fussy men, the symptoms of 
disease are relatively much more numerous among women than 
with the opposite sex; but, although the signs of special disease 
must vary in them, they are none the less tangible and accessible. 

Now these cardinal signs, as I prefer to style them, are what 
you want. They are to furnish the data without which you can- 
not make a correct diagnosis, or an intelligent prescription; and 
so far as it is possible or practical, your questions should be 
framed accordingly. The closer you keep to this rule the better 
it will be for all concerned. 

Before leaving this part of my subject I must also remind you 
that such a verbal examination as we have considered is not always 
sufficient of itself, or altogether satisfactory. My colleague, Prof. 
Hall, must catechize his surgical patients also, but his examina- 
tions do not end with asking them a few questions only. In the case 
of a displaced womb, or of a pelvic tumor we must supplement 
our queries with a physical examination that is made with the 
same care with which he would handle a dislocated joint or a 
broken leg. There are many diseases of women in which the best 
questions and answers that could possibly be framed would fail to 
give an adequate idea of the case, and in which we must have re- 
course to other and additional means of information before we can 
be satisfied either as to the nature of the ailment or the choice of 
a remedy. In my clinics and sub-clinics, it will be my pleasant 
duty to show you how to use both of these methods of examina- 
tions most appropriately and intelligently. 

II. The Study of Uterine Pathology and Diagnosis. — No 
branch of special pathology has had a more eventful history than 
that which is to engage our attention during the coming winter. 
Setting out with the idea, which is as old as Hippocrates, that a 
woman is what she is because of her uterus! her diseases have 
mostly been ascribed to some special lesion, functional or organic 
of that organ. This general conclusion was natural enough; but 
the most mischievous results followed the formation of sects, or 
parties, among which certain narrow and exclusive views obtained 



INTRODUCTORY LECTURE. 27 

and dominated for a greater or shorter period. Not to go very far 
into the past, we have had those who referred nearly all the dis- 
eases of women to uterine engorgement (Lisfranc); or to uterine 
irritation (Gooch); to uterine displacements (Yelpeau, Hodge, 
Grailly Hewitt); to uterine induration and ulceration (Bennet);to 
chronic metritis (Scanzoni); and, last but not least, to lacerations 
of the uterine cervix (Emmet). These exclusive views were in 
tarn very prevalent and popular. They are already stratified in 
the literature of gynecology, each, excepting the last, having had 
its period of rise, development and decline. Each was right as to 
the possibility of its being a factor of disease under given condi- 
tions, but wrong as to the alleged scope of its influence, or its uni- 
versal significance with regard to treatment. Each represented a 
fashion in belief and practice among medical men, which has 
either been greatly modified or has passed away. 

These and other half-truths, such as Tilt's ^iew of the supreme 
importance of ovarian inflammation, have had their influence upon 
clinical gynecology, as it is described by different authors and ex- 
plained by living teachers. Those of you who have been in prac- 
tice know this very well already; and those who have not are aware 
that your preceptors are not a*lways in accord with your text-books 
concerning the ultimate causes of ill-health among women, or the 
best method of caring their diseases. 

If we could invariably find that a warped or a luxated womb was 
at the bottom of the difficulty, the case would be plain enough, and 
the cure might not be so very tedious and troublesome. If there 
was nothing abnormal to search for but an ulceration, or even a 
laceration of the cervix uteri, the lesion could be easily made out, 
and the treatment would follow as a matter of course. If we could 
reduce the whole catalogue of women's ailments to chronic metritis, 
or ovaritis, or hyperplasia, as Broussais brought all acute, non- 
sexual disorders to depend upon a form of gastritis, the system of 
uterine therapeutics would be very much simplified, and a stereo- 
typed, inflexible set of prescriptions would be all-sufficient. 

But narrowness is another name for ignorance. Neither of 
these theories can possibly cover the whole ground of uterine 
pathology or diagnosis, to say nothing of the treatment. You 
might as well try to make a drum-head of a rabbit's skin; the thing 
is not big enough. 

In sc important a department of medicine it is a great pity that 
our knowledge should be corrupted and our influence crippled by 
such dogmas. If you wish to obtain correct ideas of gynecology, 
either as a science or as an art, I advise you not to commit your- 
selves to any exclusive theory of uterine pathology, no matter who 
first proposed it, whose endorsement it carries, or whether it is old 
or new. 

But how shall you discriminate? How are you to know what 
dependence to place upon certain classes of signs and symptoms? 



2S 



INTRODUCTORY LECTURE. 



And how shall you be able to discard what is worthless, and to 
keep only that which will be most useful? The only way to do it 
is through the process of clinical training and observation. If the 
clinics are what they should be, and if you improve upon these 
advantages as you should, it will be impossible for you to be 
unduly biased, for you will learn to balance the claims of the dif- 
ferent theories, and to take each at its proper valuation. 

Remember, therefore, that my clinics are not designed for your 
diversion, but for instructive illustration; and that, while they 
will always be aimed at the relief of suffering and the cure of dis- 
ease in the case of the patient who is the subject of our study, they 
will also enforce a lesson in the art of classifying and of identify- 
ing the lesion upon which that disorder depends. They will be dry 
and tedious enough, especially when they keep you from your din- 
ner, but with a basis of reading, and of reflection, and with a degree 
of patience and of perseverance on your part, their good fruit will 
surerely ripen in due time. 

III. The Clinical Application or the Principles of Hygiene 
to Gynecology — Without trespassing upon the domain of my 
colleague, Professor Gilman, a part of our time will be given to a 
practical application of the ounce-of -prevention doctrine to gyne- 
cology. For as the years go by the list of preventable diseases 
among women grows larger, and it is quite certain that the limit 
has not yet been reached. 

Considering the very important crises through which the young 
girl must pass, the plainest common sense would dictate that her 
bodily vigor should be fortified in advance, and maintained by 
active exercise and exposure in the open air. We cannot imagine 
a worse preparation for the healthy establishment of the mens- 
trual function; the contingencies of pregnancy, of child-birth, and 
child-bed; the wear and worry of maternity; and the final change 
which closes the drama of sexual life, than to imprison her like a 
nun, and to keep her as tender and as lacking in stamina as a hot- 
house plant, or a bit of celery. 

And yet this is what the busy physician the world over sees 
practised every day. The higher the social grade of his patients, 
the more certain is it tbe rule and not the exception, that the girls 
of the household find themselves dwarfed and crippled in the out- 
set by customs and habits that are suicidal to the best interests of 
the community. We cannot compute the harm that is done every- 
where, in what are called civilized countries, by repressing the 
natural energies, and hampering the physical life of young women 
at the most important period of their existence, just as the very 
dawn of womanhood is upon them. For it is then that they are 
most impressible to good or evil influences, physically as well as 
morally; and then that the seal of good or of ill-health is put upon 
them. 

The boys are turned out of doors, to run and romp and play, as 



INTRODUCTORY LECTURE. 29 

well as to work; to develop and defend themselves; but the girls 
are considered quite to delicate and tender for any such treatment. 
They must be housed and coddled, and kept as much as possible 
from becoming robust and vigorous, hearty and wholesome, for that 
would be vulgar and unfashionable. The sun that ripens the peach 
and tints the rose, that gilds the grass on the meadow and hill-side 
in the morning dew, must not shine upon them, or it will ruin their 
complexions, and make them tawny and coarse like their big broth- 
ers. Their blood must be thin and watery, or th^ir hands will not 
be translucent. If the heart was full and bounding, and the head 
was furnished with the proper materials for building a brain, they 
might become too masculine or too intellectual, too strong and too 
independent. 

Clinically speaking this proposition will hold good, that, unless 
the growing girl is inured to muscular exercise and to out of door 
exposure, she cannot become a healthy woman. And, if it is weak 
and sickly, the body will clog the mind, so that the indirect result 
of a lack of physical training will certainly be disastrous. This 
very defect is often a bar to the more thorough education of women, 
as well as to the establishment of their health. It is a kind of 
criminal folly to imprison our girls in schools and seminaries, with 
poor and insufficient food and fresh air, no liberty and no labor, 
while their minds are being crammed with husks of history, or 
flooded with infusions from the dry roots of a dead language. 

It is because this folly is not limited to what is called "the bet- 
ter classes," but pervades society throughout, that I shall have 
occasion to show you during the winter, and you will have need to 
know, how to recognize and to remedy its effects. For you are 
not to suppose that the large class of women who are forced to toil, 
and who are subject to the worries of active life, are thereby 
exempted from the diseases peculiar to the sex, and from which 
their more fortunate sisters often suffer unnecessarily. It is the 
extremes of indolence and overwork, and the lack of balance 
between the development and the proper exercise of nerve and 
muscle, mind and body, that works the mischief. And what applies 
to the brevet woman of the better classes, applies to the girls in 
all the schools and shops and homes in the land. 

Other questions pertaining to female hygiene that will come up 
for our consideration, as cases present themselves in my clinic, 
will include the proper aliment for body and mind, bathing and 
cleanliness, clothing and sleep, ventilation and disinfection, and 
the suitable quarantine for menstruation, advanced pregnancy, 
lactation and puerperality. 

IV. To Obtain a Correct Idea of the Scope and of the Com- 
parative Value of Uterine Therapeutics and of Uterine Sur- 
gery. — There is a tradition that surgery begins where medicine 
ends; a rule that has long been applied to general practice, to 
obstetrics and to surgery proper. But the line that separates these 



30 INTRODUCTORY LECTURE. 

two kinds of resource is so indefinite, and the faith and enthusiasm 
of those who would depend exclusively upon remedies, on the one 
hand, and on the other, of those who insist upon the necessity and 
sufficiency of manual means, are so pronounced as to keep up a 
more or less constant warfare between them. You will find that, 
in gynecology also, this is a serious question, for we need to be 
always on the alert lest we commit ourselves unreservedly, and in 
a partisan spirit, to the one view or the other. Something of the 
judicial temper will be required to determine which is most appro- 
priate, if one of them is to be used without the other, or when 
both are required. For here, as in other mooted matters, the truth 
may be assumed to be at some uncertain point between the two 
extremes. 

In consideration of the difficulties that lie in your path, I com- 
mend you. to the clinical test for the proper solution of this very 
important question. If you believe and promise that your reme- 
dies will be all powerful, the facts will not correspond; for, how- 
ever skillful you may become in their choice and application, our 
therapeutical methods, especially in gynecology, are still very im- 
perfect. Besides, there must be many remedies of which thus far 
we know little or nothing; and many conditions of disease also to 
which we cannot properly affiliate those that we already have and 
use in our daily practice. Moreover, in certain cases, there is a 
limit beyond which some operative procedure is necessary, just as 
there is in obstetrics, and in the diseases of the eye and the ear. 

If, however, you endorse and accept the opposite extreme, which 
just now is so popular, the result will not be different, excepting 
that, as the tools are bigger and more dangerous, you may do a 
great deal more harm with them. Nothing in the whole history 
of medicine has shed more lustre upon the art of healing than the 
improvement, or rather the development of uterine surgery within 
the last fifty years. In no single respect has America more just 
cause for congratulation, in all that she has done for advancing 
civilization, than for her original contributions to this useful 
department of surgery. Scores of women have gone out from this 
very clinic who will bless the memory of McDowell, of Sims, and 
Atlee, and Peaslee, and Thomas, and Emmet, and Dawson, so long 
as they live, and their children's children will have occasion to 
hold these men in everlasting remembrance. For without their 
help I could not have made the delicate and difficult operations 
which, under God's blessing, cured those poor women and set them 
on their way again. 

I know how common it is to claim all the credit in such cases 
for ourselves, and to leave f he inference in the minds of those to 
whom we minister that no one else could have done quite so well. 
And I also know that not one in a thousand of those who are thus 
benefited will ever know to whom they are indirectly indebted for 
whatever they have received at our hands; but the fact remains, 



INTRODUCTORY LECTURE. SI 

and we can afford to be frank and truthful. I am very fond of 
gynecological surgery, and proud of its achievements. The longer 
I live, and the larger my experience, the more I am persuaded 
that the women of this and of other lands have increased cause for 
thankfulness, not only for the growing opportunities that are 
afforded in our day for the development of their talents and worth, 
but also for the multiplication of means that will improve their 
health and add materially to their physical welfare and comfort. 
But I have never plucked out an abdominal tumor, or put a trust- 
ing patient in a position where there was nothing but a thin, dia- 
phanous membrane between her and eternity, without wishing 
that there was a better way, and one that was not so beset by con- 
tingencies of the most serious character. 

Among women we find that there is quite a crop of surgical cases 
that lie outside the realm of applied therapeutics, and in which 
the couditions are curable by plastic operations, and by various 
kinds of local and mechanical treatment The proportion between 
this class of cases and such as are strictly medical must be varied 
by circumstances, and with the march of improvement in gynecol- 
ogy. My clinic will not give you a correct idea in this regard, for 
it is largely composed of such knotty cases as have resisted the 
milder and more usual methods of treatment before coming to us; 
but it will teach you that we do not put a premium on indiscrimi- 
nate cutting, or operate merely for the sake of shedding blood, or 
of creating a sensation; and that the kind of advice given, and the 
value of it also, will hinge upon the correctness of our diagnosis, 
and the clearness and decision with which the indications are pre- 
sented and acted upon. If "the best physician is he who knows 
when to withhold his remedies," the best gynecologist is he who 
knows when to sheath his scapel, and when to rely upon constitu- 
tional and hygienic means for the cure of his patient. 

Between the extremes of theory and practice there is a safe and 
sensible mean. In gynecology the horizon of applied therapeu- 
tics is constantly widening, and new ground is being gained for 
those who, if they could, would greatly prefer to cure everything 
with remedies alone. But it is one thing to be captivated and 
over-confident, and quite another thing to be convinced from actual 
experience that the law of cure can possibly cover all cases, medi- 
cal and miscellaneous, indiscriminately, and that gynecological 
surgery might better be dispensed with. In my own mind, at least, 
there is no doubt that in the future we shall be able to accomplish 
more and more with our remedies ; but it is quite as probable that 
a conservative form of surgery will always continue to be neces- 
sary in the successful treatment of the diseases of women. 

If I can convince you clinically that, whether we prescribe our 
remedies, or resort to some form of surgical appliance or to oper- 
ative interference, in the practice of this specialty, the conserva- 
tive idea is the better one; and can encourage you always to culti- 



32 INTRODUCTORY LECTURE. 

vate that idea, your gynecological training will amount to some- 
thing, and your professional advice will be worth having. For 
this idea combines strength for common objects with separate 
resources for special ends. Both elements in the combination are 
salutary, and neither should be allowed to overpower or to super- 
sede the other. 



LECTUEE I. 

GENERAL PATHOLOGY. 

THE SEVEN CRITICAL PERIODS IN THE LIFE OF WOMAN. 

1. Puberty. — Childhood, Girlhood, Womanhood, Clinical history of; Comparative risks of; 
Not identical with nubility; Early marriage and; Delayed; Case. 2. Menstruation — Causes 
of Suffering in ; three steps in; Influence of diathesis upon; do. of travel; do. of the hasmor- 
rhagic tendency. Case.— Effect of intercurrent disease upon; do. of the cachexiae; do. of 
mal-treatment; the menstrual cachexia. 

Before we proceed to study the different diseases of women 
separately, we must consider some of the principles that pertain 
to the general subject of gynecology. A knowledge of the general 
pathology of those diseases will be indispensable in your practice, 
and, so far as it is possible, that knowledge should be acquired at 
the beginning of your course. For the lack of familiarity with 
these underlying principles, the physician is often placed at a dis- 
advantage, and, what is worse than all beside, the improvement 
and the recovery of his patients are very seriously involved. 

Unless you are extremely careful and resolute, there is a double 
temptation that will divert your minds, and keep you from devot- 
ing the necessary time and attention to these preliminary studies. 
The fact that you are permitted to enter my clinics, and to wit- 
ness the great variety of cases which are treated before the class, 
places a peculiar temptation in your way as beginners. For it 
may induce you to follow the example of the artist who began to 
paint before he had any knowledge of drawing. Add to this the 
propensity for prescribing, which is almost universal, and which, 
unless we are very cautious, is apt to be gratified in inverse ratio 
with our ability and experience, ani the risk that you will lose your 
taste for the deeper study is very great. 

The first elements or principles of this branch of medicine and 
surgery lie in the very nature of the subject, — I mean in the 
peculiar physiological and clinical history of the class of patients 
who will come under our care in the practice of this specialty. 

33 



34 thl diseases of women. 

Some one has said that " every man's life contains a novel of* at 
least one volume." Let me tell you that every woman's life 
includes a clinical history of more than one volume. For, if we 
study the several crises through which she must pass, is passing, 
or has passed, we shall find that her health and physical welfare 
are beset by vicissitudes that are peculiar to herself. Nor is this 
all. These contingencies are superadded to the risk of the more 
ordinary ailments to which others are liable. So that, in addition 
to her sexual disorders, she may have pneumonia, dysentery, 
typhoid fever, tuberculosis, or almost any other disease, or acci- 
dent that is mentioned in our works on Clinical Medicine and 
Surgery. 

Apart from all other considerations, therefore, this fact alone 
should suffice to elicit your sympathy and interest in the study of 
Gynaecology. The thought that, by close application and stiufy, 
and by a conscientious improvement of the advantages which it is 
my duly and privilege to bestow, you can in the future mitigate 
the sufferings and lighten the burthens that the poor women all 
around you are bearing, should stimulate you to put forth your 
best efforts in this direction. For every case that I shall show 
you in my clinic will have its counterpart in your experience 
bye-and-bye, and every ki wrinkle " that is dropped in my lecture- 
room will be needed to furnish your stock of expedients for 
sudden and serious emergencies. 

Since "Art is long and life is fleeting," and since we have so 
much to do, and so little time in which to accomplish our work, 
we will come at once to the subject before us which is 

A CLINICAL STUDY OF THE CRISES IN A WOMAN'S LIFE. 

The grand, distinguishing feature of woman is the fact that her 

physiological and medical history are included 

The seven crises. in the sevm cr } t j ca i periods to which she is 

subject. These periods are : (1.) Puberty, or the first establish- 
ment of the catamenia ; (2.) Menstruation, or the periodical 
return of the menses; (3.) Pregnancy, or the period of repro- 
duction; (4.) Parturition, or that of childbirth; (5.) Puerperal- 
ity, or the state of lying-in; (6.) Lactation, or the nursing 
period; and (7.) the Climacteric, or the " change of life," as it is 
commonl}' called. 



GENERAL PATHOLOGY. 35 

It will be impossible for you to arrive at a correct appreciation 
of the subject before us without a careful study of these crises as 
essential factors in the diseases of women. No man, and no per- 
son is prepared to explain or to treat these peculiar diseases 
intelligently and skilfully without an adequate 

Necessity for the study idea f th influence whSch these periods exert 

ot these crises. *- 

upon the health and the welfare of women. 
For the whole subject of uterine pathology, as it is termed, lies 
in these cycles and what concerns them. 

I. Of Puberty. — The first epoch in the sexual life of woman 
is puberty. It consists essentially in the arrival of that period in 
which the ova are ripened and discharged, with the incidental 
sufferings and symptoms that belong to the establishment of the 
menstrual f unc t i on . 

The infancy of the girl does not differ essentially from that of 

the boy. There is, perhaps, a touch of softness, of delicacy, and 

of pliability in her organization, that are half- 

Childhood. l - . J . r , 

way distinctive ; but, in general terms they are 
identical. Their looks, habits, tastes and predispositions are the 
same. They grow and thrive upon the same food, in the same 
school-room, or nursery, and are full of sympathetic relations, 
but without the passions and propensities of after-life. They are 
subject to the same diseases, which are curable by the same treat- 
ment; and they occupy a like place in the esteem of the family, 
the friends, and the general community. 

But time works notable changes in the young girl. For it 

gives a more decided tone to the delicate and the almost imper- 

„ , ceptible shades of difference between her and 

Girlhood. l . 

her male companion. At a period varying 
from the tenth to the twelfth year, in this latitude, her individu- 
ality begins to assert itself. Her tastes and inclinations are 
changed, and she becomes shy and taciturn, or forward and 
capricious. She is timid and reserved, but sensitive, confiding, 
and tender-hearted. The womanly traits are soon evolved and 
matured, and she is no longer the non-sexual creature that she 
was before her emotional and physical natures were so wonder- 
fully developed. 

Henceforth her role is declared, and she must play it with all 



36 THE DISEASES OF WOMEN. 

the risks that threaten the sex to which she belongs. The sexual 
life dawns amid contingencies that are more 

Womanhood. . 

numerous and more serious than you may have 
supposed. For, although the ovaries were perfectly formed 
during foetal life, and were full of ova at the birth of our subject, 
yet they have lain dormant until the date of puberty. And, although 
the womb, and the whole generative intestine were present at first 
as they now are, yet, until now, they never were the seat of any 
especial functional activity. 

And henceforth her diseases will be peculiar, and very different 
from those to which she has already been subject. This chapter 

is one of the most interesting in her whole 

Her i linical history. ,. . , . . A n . J . , t • i i n 

clinical history, lor it involves and includes all 
the rest. We must comprehend this crisis and its influence 
throughout the whole of her menstrual life, or very much that 
follows will be a puzzle and an enigma that we shall certainly fail 
to solve. 

There is a common impression that the most serious disorders 

which date from puberty are referable to a delay in the prompt 

establishment of the menstrual function. It is 

The comparative risks. , n . , . • i i i i • 

at puberty. \\q\& that, it a girl does not begin to menstru- 

ate before her sixteenth, eighteenth, or twen- 
tieth year, she will almost necessarily suffer in consequence. But 
I insist, that, practically considered, this is a wrong view of the 
case. For while the delay, if it is too tardy, is neither natural 
nor desirable but is sometimes decidedly harmful, still, as a rule, 
the risk is greater if the flow begins too early as, for example, 
in the tenth, the eleventh, or the twelfth year. 

One reason why a precocious puberty is apt 
arrnoTthe a saL nUbilityto be followed sooner or later by ill health, is 
that with parents and with physicians also, 
puberty and nubility are regarded as synonymous, or identical. 
The prevalent idea is that, since ovulation implies the possibility 
of conception, it also signifies the propriety of an entrance into 
the marriage relation. So that, even although the girl who has 
menstruated so early does not marry while she is still very young, 
the chances are that she will be placed in a wrong relation to the 
opposite sex, while she is a mere child in every other respect, 
before the generative organs are fully developed, and before her 



GENERAL PATHOLOGY. 37 

physical maturity has arrived. Acting upon the hint that ma- 
ternity is possible, she is placed at a most unfortunate disadvan- 
tage. 

This is the reason why early marriages often turn out badly. 
The menstruation was premature, and the wedding also; and 
then the first pregnancy ends in a miscarriage, 
or in a labor that is tedious and impracticable 
because of the youth and immaturity of the party who is most 
concerned. And after this comes a chapter of consequences that 
are likely to be entailed upon the poor woman for life. 

Another reason why a premature advent of the " flow " may 

have its mischievous results is that, coming thus early, the young 

girl may be ignorant of its meaning or import, 

ne^°c? nCe and S6lf " ( as alas! so man y thousancls of them are), and 
therefore may neglect herself sadly at this par- 
ticular period. Knowing nothing of the consequences that may 
follow, she Avill be very apt to get her feet wet, to take a cold 
bath, or to do something to check the flow, and to compromise 
her health. In my clinic I shall often have occasion to refer you 
to this as one of the sources of menstrual disorder, and of uterine 
and ovarian disease in after life. 

If puberty is delayed by reason of constitutional or general 

causes, the case is serious and will need to be inquired into. 

There arefou?* of these causes, either of which 

puberty" ° f ^^ ma y retard the nrst appearance of the menses, 
viz., (a.) an impairment of the quality of the 
blood; (b.) depraved nutrition; (c.) nervous and mental exhaus- 
tion; and (d. ) the tuberculous or scrofulous diathesis. 

If the blood is impoverished, or lacking in the elements that 

are requisite for the healthy and vigorous performance of the 

bodily functions in a growing child, it is not to 

Impoverished blood. ° 

be supposed that it would contribute anything 
to the establishment of a new and a different function. If the girl 
is the subject of chlorosis, of anaemia, or of chloro-amemia, the 
blood may not be rich enough to stimulate the ripening of the 
ova, the first menstrual discharge may go by default, and the 
second and subsequent attempts to put this function into opera- 
tion may not be any more successful. In this case the general 
■cause is responsible for the result. 



38 THE DISEASES OF WOMEN. 

Or, if the nutritive process is badly performed through a lack 
of proper food, fresh air and exercise, caprice 

Depraved nutrition. . . . , __ J -, -,. 

or whim, or any other cause, JNature may decline 
and absolutely refuse to create a new demand and a new drain 
upon the resources of the economy until this state of things is 
remedied. There is no more fertile source of mischief to our 
young women than the abominable diet that is furnished them in 
many of our boarding schools and seminaries, at a time of life 
when they should be well-fed and nourished. For to confine 
our young girls to a bill of tare that would dishearten and dis- 
courage an anchorite, is a reproach to our boasted civilization. 
In the same general way it may happen that nervous and men- 
tal exhaustion shall interrupt the "regular course of things" 

with the class of subjects under consideration. 

Nervous exhaustion. . . . _. , . 

W e all know that this condition is a lertile 
source of mischief with many of those who have already begun 
to menstruate. In such cases too great a nervous strain may 
arrest the flow altogether for months, and sometimes for years. 
There are several of these cases in myelinic at this moment. So, 
likeAvise, when the time for this crisis, which we call puberty,, 
has arrived, if the girl is subjected to excessive mental w T ork or 
worry, if her brain fags, or her nerves " fly all to pieces," and 
the strain is kept up, we may reasonably expect that the initial 
step in this process will not be taken until the conditions are 
changed. 

The tuberculous habit often delays the first appearance of the 
menses, and, indeed, it often deranges this function most seriously 

at other times also. You should not forget to 

The different diatheses. . .... . ° 

look especially lor pectoral symptoms, a hack- 
ing cough, haemoptysis, night sweats, and a quick pulse, where 
the menses are tardy in one who is predisposed to phthisis. The 
scrofulous cachexia, as a rule, is accompanied by delayed men- 
struation ; but girls who have a curvature of the spine are apt to 
" flow " early and copiously. 

An interesting case came to our clinic a few days ago, in which 
the delay of the catamenial function was clue to a bronchocele : 

Case. — E. L , aged fifteen, has never menstruated. She is 

a bright, active girl, and has been closely confined in one of our 
city schools. Two years ago both lobes of the thyroid gland began 



GENERAL PATHOLOGY, 39 

to develop simultaneously. This swelling has slowly increased in 
size until the circumference of the neck is fully 

From bronchocele. one _ half larger than jj. Qught to be; her gQR _ 

eral health is good, but her mother says that alter active exercise 
she is subject to slight attacks ol palpitation of the heart. There 
is no protrusion of the eyeballs nor any derangement of vision. 
She has no signs of anaemia, and there have been no symptoms 
that indicate the establishment of the menstrual flow in her case. 
It is not characteristic of her family that menstruation shall 
begin at a later period than usual; nor have any of her relatives 
ever had bronchocele. She was directed to take spongia 3, four 
times daily. (This case improved steadily on spongia.) 

Certain diseases are cured by puberty. Chlorosis, chorea, 
incipient phthisis, and some eruptive affections may cease by 
limitation when the monthly flow is fully established. It is in 
ignorance of this fact, that cures of these diseases are often 
ascribed to remedies which have been given just at that particu- 
lar time. What is equally remarkable is, that the phthisis and 
the diseases of the skin, which apparently have been cured at 
puberty, are apt to return at the climacteric. 

Among the diseases that follow the initiation of this remark- 
able function, hysteria is perhaps the most prominent. It is very 
rarely that a young girl has hysteria before puberty, or during 
the pre-hysteric age, and it is quite as exceptional if a woman 
has it after the menopause, or during the post-hysteric period of 
her life. 

In a very large proportion of cases of epilepsy among women, 
the disease dates from the first menstruation, or from the natural 
effort to bring on the flow. 

If to these peculiar nervous disorders we add the whole list of 
the diseases of menstruation, of pregnancy, and of each of the 
other critical periods already spoken of, you will see how impor- 
tant a relation this first step in the direction of womanhood bears 
to what are properly styled the Diseases of Women. In our 
search for the beginnings of uterine and ovarian disease, we shall 
have frequent occasion to refer back to, and to inquire after, the 
peculiar experiences of the patient at the very dawn of her men- 
strual life. And we shall often find that something in the charac- 
ter of the pains that she had, or in the weight in the hypogas- 
trium, the headache, the vertigo, the malaise and lassitude, the 



40 THE DISEASES OF WOMEN. 

palpitations, the disgust of food, or the morbid appetite, the 
extreme sensitiveness, the spasmodic tendency, or the emotional 
uproar, will help us to clear up the diagnosis and to individualize 
the case. No matter if twenty or thirty years have intervened, all 
the obstacles that were in the way of the prompt, free, natural 
and almost painless establishment of this function may need to be 
known before we can proceed intelligently with the cure of our 
patient. 

II. Of Menstruation. — Whether we accept the prevalent 
theory that menstruation depends upon ovulation or not, the 
fact remains that the monthly molimen is characterized by states 
of the pelvic circulation and innervation which are easily dis- 
turbed and changed into the inflammatory process. 

The menstrual congestion which is a necessary condition of the 

subsequent flow, is the cause, in a large part, of the intra-pelvic 

pain and distress that almost always attends the 

Causes of suffering. „ ,. ,, . c . „. . , ,. 

performance of this function. The weight of 
the womb is increased by its temporary engorgement. Its deli- 
cate lining membrane begins to undergo the changes which bring 
about its detachment and final discharge. This "nidation," as it 
is technically called by Dr. Aveling, and the moulting that fol- 
lows is analogous to the growth and separation of the decidua in 
pregnancy and labor. The exfoliation of the 
Three steps m the pro ^ecidua menstrualis, is, in fact, beset by con- 

eess. . . 

tingencies both before, during, and after the 
" period." And the clinical symptoms which we have to study 
in menstrual disorders concern these three special stages of this 
process. 

You will often have occasion to observe that 

the chief complaint which the woman makes 

of suffering at the month, dates from two or three days to a 

week before the beginning of the flow. In other cases, she is in 

greater pain and distress after the flow has 

begun, and so long, indeed, as it continues. In 

a third series of cases, the suffering is almost entirely limited 

to the time when the proper discharge has 

ceased, or changed into a leucorrhceal flow. 

Very exceptionally, as in inter-menstrual dysmenorrhea, she 



GENERAL PATHOLOGY. 41 

may suffer most at a time that is half-way between the periods. 

A little reflection will satisfy you of the importance of this 
subject. In order that a woman should be healthy during what 
is termed her menstrual life, excepting only while she is pregnant, 
or during lactation, the function of which we are speaking should 
be regularly and properly performed. Each of the three steps 
in the process should be taken promptly and they should succeed 
each other in a natural manner. 

If the nervous conditions that control the circulation are such 
as to drive or to divert the blood from the 

Anticipating symptoms. , . , , , , . . 

pelvis to the brain or elsewhere just when it is 
needed within the ovarian and uterine vessels, as a condition of 
menstruation, the secretion will be arrested or impaired. 

If the blood itself is too poor to furnish the necessary stimulus 
for the ripening and extrusion of the ovule, the whole function 
of menstruation may, for the time being, at least, go by default. 

If the uterus has toppled over backwards and obliterated the 
canal of the cervix at the internal os- uteri, the menstrual 
changes that are proper to the cavity of the body of the womb 
will be very much disturbed, or cut short in their first stage. 

If the neck of the womb is narrowed, or partially obliterated 
from any other cause, the patient will have to pass through a 
period of suffering which is the counterpart of the first stage of 
labor, and which, although it recurs every month, is as hard to 
bear as a veritable childbirth. 

Or, if we suppose that the flow has begun in a normal manner, 
the most serious consequences may happen through its interrup- 
tion. What is called an intermittent form of 

Accompanying symp- . , 

toms> menstruation, or one m which the now begins 

and stops alternately, is always a painful variety 
of menstrual disorder. There is perhaps no case of inflamma- 
tion of the entire lining membrane of the womb, in which men- 
struation is not painful from the beginning to the end of the 
period. The discharge is sometimes arrested by shock, as from 
fright, or some form of mental emotion; by falling, or by strain- 
ing, as in lifting something heavy; by coitus, and by getting the 
feet wet. And the effects are all the more serious because the 
mischievous influence has been applied during the flow, when 
there is a greatly increased susceptibility, with a diminished resist- 
ance on the part of the generative organs. 



42 THE DISEASES OE WOMEN. 

Clinically speaking there is no doubt that menstrual disorders 
are frequently caused and perpetuated by a lack of care during 
the period, in some such manner as dyspepsia may be induced by 
causes that are brought to bear Avhile the stomach is busy with 
dissolving the food. 

And so likewise with the third act in this wonderful physio- 
logical process, which, to a healthy middle-aged woman, is "as 
inevitable as one's shadow." The rapid degen- 

Subsequent symptoms. . . . . , 

eration ol the uterine mucous membrane, the 
carrying away of the effete debris, and the final " parturition of 
the ovule," as Tyler Smith so aptly termed it, are steps that are 
decidedly critical. For, if a decidua is removed at every period; 
if this removal is accompanied by more or less peristaltic action 
of the uterine muscular fibre; and if it is followed by haemor- 
rhage, the case is one of labor in miniature, which, like the 
period of puerperality, has its own clinical significance. 

These considerations with regard to the general pathology of 
menstrual disorders, have their counterpart in the proper treat- 
ment of those disorders, whether it be medical 

Practical deduction. . . 

or surgical. Ihis, indeed, is the key to what 
might be styled menstrual therapeutics, and in your practical 
lives as physicians, whether you become specialists or not, you 
will have occasion to use it very often. 

There is another class of facts which you will need to remem- 
ber in this connection. The conditions that influence and modify 

the course, progress and termination of diseases 

Influence of diathesis,, i , , , . -. ,1 -, 

etc that are not catamenial, impress themselves 

upon this class of affections also. There are 
personal and family idiosyncrasies that may so change the clinical 
history of amenorrhcea, dysmenorrhcea, and menorrhagia as 
almost to destroy their identity. When either of these disorders 
occurs in a woman who is subject to scrofula, to rheumatism, to 
chlorosis, to syphilis, or to any serious affection of the skin, its 
special pathology, and its special therapeutics will be modified 
accordingly. 

Nor should you forget what I feel like insisting upon very 
strongly, that the diseases of which we are 

Influence of travel. ,. ., ■, . -, ,, . a -,, 

speaking are quite as decidedly influenced by 
external circumstances, and especially by changes of latitude, as are 



GENERAL PATHOLOGY. 43 

asthma, tuberculosis, or intermittent fever. This fact needs to 
be borne in mind, because, in these days of rapid transit, and 
of cheap transportation, when everybody travels, sufficient atten- 
tion is not always paid to the climatic vicissitudes of journeying 
from one end of our country to the other. 

Some of you remember a very marked illustration of the modi- 
fying influence of the haeniorrhao-ic diathesis 

Influence of the hsem- ^ " • tit- 

orrnag-ic tendency. upon menstruation that we have had m our 
clinic. I will recall the principal facts to your 
mind : 

Case. — For some years, four of the members of one family 
have been coming to our out-clinic. The eldest of the three 
daughters consulted us for a pronounced anaemia with periodical 
haemoptysis, and a delay in the establishment of the monthly 
flow. The second one had epistaxis at puberty, which was evi- 
dently vicarious of menstruation, and when the uterine flow was 
finally established it was very irregular. The third menstruated 
once only at fourteen, but not again for several months, and was 
sickly and complaining meanwhile. And the mother, who was 
passing through the climacteric, not having ceased to flow at 
forty-nine years of age, was suffering from incipient hemiplegia. 

Intercurrent diseases of an acute or sub-acute type have much 
to do with modifying and complicating the clinical history of 
menstruation. During their existence, as for 
renf Sease° f lnterCUr " exam Ple, while a menstruating woman has 
typhoid fever or pneumonia, her periods are 
very likely to be interrupted. Sometimes she will have a sus- 
pension of this function, or a kind of temporary amenorrhoea 
that is limited by the duration of the fever, or of the inflamma- 
tion, whatever it may be. At other times, more especially if her 
general condition is adynamic, or if she is addicted to haemorrhage, 
the flow may be too frequent and too copious. In either event 
the crisis of the intercurrent disease from which her recovery 
dates, is often the point of departure for menstrual difficulties 
that she never had before. For this reason the management of 
acute diseases occurring in women demands especial care. 

The same rule has an indirect application also. Where conva- 
lescence from acute disease has not been thoroughly established, 
and the patient has drifted into a cachectic condition that may 
continue indefinitely, disorders of menstruation are very likely to 



44 THE DISEASES OF WOMEN. 

ensue. The confirmed state of cancer, whether it be uterine or 

not, of phthisis pulmonalis, of chronic dvspep- 

ioufcrhexir beVar " sia > and he P atic disorders, of pelvi-peritonitis, 

and of pelvic cellulitis, are almost invariably 

complicated with one or more of these affections. 

If your observation accords with mine, you will learn that a 
considerable share of the menstrual difficulties which you will be 
influence of a ai-treat-called upon to cure are the sequelae of an excess 
ment - of local treatment, in the way of cauterization, 

dilatation, or incision of the cervix uteri, and the wearing of ill- 
assorted, ill-adjusted pessaries, that may have caused an untold 
amount of suffering, and had the effect to upset the menstrual 
function altogether. It will be my duty to teach you how to 
apply these resources in such a way as to make them of real 
service to your patients, and how to avoid the harmful conse- 
quences that are so often entailed upon women by their careless 
and indiscriminate employment. 

In conclusion I must remind you that chronic disorders of the 

function of which we have been speaking, whatever their cause 

or complication, may develop a menstrual 

The menstrual cachexia. . . ~. 

cachexia, which is sometimes as incurable as 
that of chronic aortitis, or carcinoma. This fact which has been 
verified by clinical experience under all the known methods of 
treatment, will have the effect to make us chary of promising to 
cure these disorders indiscriminately and invariably. 



LECTURE II. 

GENERAL PATHOLOGY— CONTINUED. 

3. Pregnancy.— The physiology of; the diseases that are caused by; relation of, to uterine 
displacements: do. to cervicitis ; the common diseases of pregnancy ; changes of the 
blood in ; do. of the heart in; rheumatism in; do. nervous affections; do. metro-cere- 
bral disorders ; do. pulmonary, digestive, and uriuary derangements. The diseases 
that are cured by pregnancy; the vis medicatrix of. Diseases that co-exist with preg- 
nancy; ovarian and fibroid tumors, etc. 

III. Pregnancy. — The period of pregnancy, which begins with 
conception and ends with labor, is characterized by a great variety 
of physical changes, which, although they are natural and self- 
limited, as a rule, do often modify the subsequent health of women. 
This is why, in the case of those Avho have borne children, whether 
prematurely or at term, pregnancy may be considered as a critical 
predisponent of disease. 

If the uterine tissues were not developed in an extraordinary 

degree; if ovulation and menstruation were not 

The physiology of P reg- suspenc i ec i ; if the circulation and innervation 

n£Lncv A 

of the pelvic and abdominal viscera were not 
greatly augmented ; if the heart and the liver were unchanged in 
structure and not overburdened with an increase of duty ; if the 
demands upon the nutritive and nervous systems were not in excess 
of the usual needs of the economy; and if the moral and physical 
natures were not disturbed in so remarkable a manner during 
pregnancy, you may depend upon it that a large share of the 
diseases that are entailed upon women would have no existence. 

In a liberal, but not in a literal sense, all the diseases that are 
peculiar to women, excepting only those that belong to menstrua- 
tion, must be directly or indirectly related to pregnancy. The 
contingencies of childbirth, of the puerperal state, and of lacta- 
tion, therefore may be said to date from the beginning of gesta- 
tion. 

I think it will be profitable to consider this subject under the 
three general heads of (1) the diseases that are caused by, (2) those 
that are cured by, and (3) those which may co-exist with pregnancy. 

45 



46 THE DISEASES OF WOMEN. 

1. Of the Diseases that are Caused by Pregnancy. — In this con- 
nection I shall not speak at length of what are commonly called 
the diseases of pregnancy, as for example, morning sickness, 
caprices of the appetite, incidental disorders of digestion and of the 
circulation ; but of the more chronic and permanent affections to 
which women are predisposed by reason of their having been preg- 
nant, and from which they suffer after the period of gestation has 
terminated. 

Perhaps the different varieties of uterine displacement should 
head this list. If we remember that the changes 

Uterine displacements. . . . , . „ . 

which take place in the uterus prior to the fourth 
month are almost exclusively confined to the fundus and body of 
the organ, we shall be able to explain the comparative frequency 
of flexions and versions of the womb that follow upon early abor- 
tion. The greater relative frequency of prolapsus as a sequel to 
miscarriage in the later months must be ascribed to the develop- 
ment of its lower segment at that period of pregnancy. 

Depaul and others have noted the fact that the growth of the 

uterus during pregnancy is not uniform upon its different sides 

or surfaces any more than at its two extremities. Nothing is more 

probable than that these one-sided conditions 

o?Z U grav1r u 1^? ntoften continue after delivery, more especially 

if that delivery was accidental or premature. 

When the risks of defective involution which attend upon all 

cases of miscarriage are added to such conditions, the source of 

very many cases of uterine deviation is almost positively known. 

So, likewise, the torsion or twisting of the uterus, which occurs 

in the last months of pregnancy, and which 

Twisting- of the womb. .,, . n z . . . , 

usually turns it toward the right side, may give 
it a lateral inclination that it will keep for a long time after the 
child is born. This result is facilitated by the relaxation of the 
round ligament on the opposite side, which gives the organs a kind 
of squint or divergent strabismus. You have observedthis obliquity 
in our puerperal wards when we have been studying the changes 
that occur in the womb during the first ten days of the lying-in ; 
and I shall often have occasion to illustrate this kind of deviation 
arising from the same cause, in my general clinic. 

Naturally enough, the statics of gestation, as well as the extra- 
ordinary development of tb* intra-pelvic tissues, the migration of 



GENERAL PATHOLOGY — CONTINUED. 47 

the womb from the pelvis to the abdomen, and the stretching of 

all the uterine ligaments are so many factors in 

mefgame P n°t n s. theUter " causing and complicating the displacements of 

the organ, that come either in the early months 

of pregnancy, or that follow its close. 

There is another group of affections from which many, if not, 

indeed, most women would be exempt if they 

cervical inflammation became pregnant. I allude to the differ- 

and ulceration. ^ . 

ent forms of inflammation and ulceration of the 
uterine cervix. Those of you who have been engaged in the study 
of obstetrics know what is understood by the ramollissement or 
softening of the cervix, its change of form and structure, and its 
final obliteration at term. These processes, which are physiologi- 
cal and natural in themselves, bring about such a modification in 
the nutrition of the parts as renders them much more liable to dis- 
ease than they would otherwise have been. Clinically considered, 
the virgin cervix is very different from the cervix of one who has 
reached the sixth month of pregnancy or who has gone her full time. 
And there are also important differences between the cervix in 
the first and in subsequent pregnancies; or, technically speak- 
ing, between the cervix of the nulliparous and the multiparous 
uterus. 

In the treatment of corporeal cervicitis, and of endo-cervicitis, 

as well as of cervical induration and ulceration, I consider it very 

important to remember that either and all of these lesions may 

Effects of a by-gone have their root in the evolution and the involu- 

pregnancy upon the . 

cervix. tion of the neck of the womb, during and after 

pregnancy. 

We have good authority for the statement that epithelial cancer 
of the neck of the womb never occurs except with those who have 
borne children. 

The modifications that are proper to the uterine mucous mem- 
brane during gestation are peculiarly delicate, 
and of the greatest possible interest to the gyn- 
aecologist. These modifications include a great 
and growing increase of its surface, and of its vascularity; the 
formation, separation and final moulting of the decidua; the 
organization and detachment of the placenta ; the development 
of a new membrane to take the place of the old one; and the 



Changes in the endo- 
metrium. 



48 THE DISEASES OF WOMEN. 

retrogressive changes that pertain to the involution of the uterus 
after it has been emptied of its contents. 

If these changes are interrupted or interfered with, the risks 
of inflammation are sometimes verv great, and 

Effects of. ,_ _ ■ _ * -, „ 

the consequences may last tor years m the form 
of ordinary chronic metritis, exfoliative metritis, menorrhagia, or 
an intractable uterine leucorrhoea. 

What we have said of cervical lesions as contingent upon preg- 
nancy is equally true of the common form of metritis that occurs 
in general practice. For, if her womb has not been developed by 
a contained embryo, or something like it, as, for example, in case 
of uterine polypi, or fibromata, it seldom happens that a woman 
has chronic metritis, unless, indeed, it be the result of some mis- 
chievous local treatment or appliance. 

It would not be reasonable to suppose that the peritoneum, 

which is the outer envelope of the uterus, should 

ch^el ° fPerit0neal tail t0 Participate in the changes of structure, 

and in the morbid risks that, without exception, 

are proper to all of its tissues during the period of utero-gestation. 

You know that this delicate serous membrane, after covering 
the posterior surface of the bladder, is reflected upon the anterior 
wall of the uterus, so that it invests about three-fourths of this 
organ in front ; that it passes over the fundus and descends upon 
the posterior face of the womb until it lines the Douglas cul-de- 
sac, whence it re-ascends upon the rectum. You also know that 
the broad ligaments are formed of duplicatures of this same mem- 
brane, and that the utero-sacral and the utero-vesical moorings of 
the womb are made of the same material, with a few muscular 
fibres interspersed. This is the genital peritoneum. 

Rouge t is authority for the fact that there is a very intimate 

union between the muscular parietes of the womb and its investing 

peritoneum, and that during pregnancy, this 

ton[tf s in0fmetr0 " Peri " union continues > so that the peritoneum does 
really participate in the hypertrophy and other 
textural changes that are proper to this period. Add to this, that 
when the uterus passes from the pelvis to the abdomen, where it 
may have space for its development, the ligaments are put upon 
the stretch, and sometimes seriously injured. These circumstances 
predispose many women to pelvi-peritonitis, which disease is 



GENERAL PATHOLOGY CONTINUED. 49 

much more troublesome and common than you may have sup- 
posed. If my own experience in private prac- 
origin of pelvic pen- ti d ag a olinical teacher, may be taken as a 

tonitis. ' . J 

criterion of the facts in the case, I should say, 
that while pelvic cellulitis may, and does sometimes occur in those 
who have never conceived, pelvi-peritonitis, like the cauliflower 
excrescence, does not. It is true, however, that in a considera- 
ble proportion of cases, these two diseases are not altogether 
distinct. 

In consequence of pregnancy, the liability to inflammation of the 
pelvic cellular tissue is very much increased. You will find a con- 
firmation of this fact in our lying-in wards and in 

^Origin pf pelvic cellu- the Mstory of many cases j n my dinic on Wed _ 

nesdays. It often happens that, because relapses 
of cellulitis in the non-puerperal state are so directly related to 
the menstrual return, the real origin of the disease, as a sequel of 
pregnancy, is overlooked. En passant, it may be as important to 
treat these cases with especial reference to their beginnings during 
gestation, no matter how remote it may have been, as it sometimes 
is to treat prolapsus uteri with reference to a defective involution 
of .the womb during the early puerperal period. 
The etiological results of the changes in the muscular tissue of 

the uterus during gestation will be considered 

iartunf c eSintheVaSCU " when we come to s P eftk of the post-partum in- 
volution of that organ. 
Having thus considered the modifications that are proper to the 
generative organs during pregnancy, the effects of which do not 
wholly disappear in after life, we must study the results of this 
condition upon the other organs and functions 

of T p h r e egra r c.y ndiSeaSeS ° f the £ elieral economy. In this regard the 
diseases of pregnancy, as they are commonly 
termed, are significant, not only during the period of utero-ges- 
tation, but afterward, and because of their sequelae. 

To facilitate this study I have arranged a table upon the black- 
board. It is imperfect, but it will give you a list of the more 
prominent disorders to which women are liable during pregnancy. 
The groups of diseases naturally involve the more prominent 
organs and functions, and are more or less serious, according to 
circumstances. 

4 



50 



THE DISEASES OF WOMEN. 



TABLE OF THE DISEASES OE PREGNANCY. 



The Circulatory System. 


The Nervous System. 


The Digestive System. 


1. Of the Blood: 


1. Of the Mind: 


1. Of the Mouth . 


a Plethora. 


a Irritability, timidity. 


a Stomatitis. 


b Anaemia. 


b Melancholia, vertigo. 


b Toothache. 


c Chlorosis. 


c Capricious inclina- 


c Ptyalism. 


d Uraemia. 


tions. 




e Hydremia. 


d Often entire charjge 




/ Chloraemia. 


of temperament. 




2. Of the Circulatory Organs : 


2. Of the Sensory Nerves : 


2. Of the Stomach: 


a The heart. 


a Pain: headache. 


a Morning sickness and 


b Palpitation and syn- 


b Neuralgia. 


anorexia. 


cope. 


c Over-sensitiveness. 


b Nausea and vomiting. 


c Hypertrophy, etc. 


d Insensibility. 


c Pyrosis. 


d Veins; varicoses. 




d Cardialgia. 
e Haematemesis. 
/ Capricious appetite. 
g Catarrh of the stom- 
acn. 


3. Of the General Circulation. 


3„ Of the Motor Nerves : 


3. Of the Bowels : 


a (Edema. 


a Spasms ; convulsions^ 


a Constipation. 


b Haemorrhoids. 


b Eclampsia. 


b Diarrhoea. 


c Haemorrhages. 


c Epilepsy ; chorea, etc. 


c Dysentery. 


d Varicoses. 


d Paralytic conditions. 








4. Of the Liver: 

a Torpidity of, etc. 
b Hypertrophy of. 
c Acute atrophy of. 



If we take the circulatory system, we find that the altered char- 
acter of the blood, which in a considerable proportion of cases is 
contingent upon pregnancy, continues thro ugh 
changes m the blood puerpera j ifcy and lactation, so as to impair the 

during pregnancy 1 i J > i 

health of the mother more or less permanently. 
This is a class of causes which is very obscure, and therefore 
likely to be overlooked. 

Concerning the heart itself, there is no question that its struc- 
tural changes during pregnancy are often as pro- 
nounced in their way as are those which occur 
in the uterus. The most decided of these changes consists in a 
hypertrophy of the left ventricle, the walls of which may become 
increased from one-fourth to one-thirl of their thickness. Their 
texture is more firm and their color more bright, while the auricles 



Changes in the heart. 



GENERAL PATHOLOGY CONTINUED. 51 

and thfi right ventricle retain their normal thickness. If the right 
ventricle is also hypertrophied, it will give rise to pulmonary 
congestion and haemoptysis. 

It the hypertrophy of the left ventricle results from the nat- 
ural impediment to the uterine circulation during pregnancy, it 
must be regarded as conservative, or compensatory, the same as if 
it had been caused by valvular lesions; and if the hyper-nutrition 
of its parietes, like that of the uterine tissues, is confined to the 
period of gestation, and passes off with it, the cause being with- 
drawn the lesion may disappear. But if anything interferes with 
a return of the normal conditions of the general circulation, the 
hypertrophy will not be removed. 

In this manner a single pregnancy may develop an acquired pre- 
disposition to cardiac diseases which subsequent pregnancies, more 
Changes as a predis- especially if they occur in rapid succession, will 
ponent of cardiac dis- be very likely to confirm. Indeed, it sometimes 
appears that this predisposition is ultimately 
changed into an exciting cause, as when it induces epistaxis, 
haemoptysis, metrorrhagia, or apoplexy. 

When this ventricular lesion exists in women who have suffered 

from the rheumatism that is sometimes caused by pregnancy, Ave 

may look for valvular complications which are 

Effects of the rheuma-. . 

tism of pregnancy. in the way of a perfect recovery. For in this 
case the compensating hypertrophy will not 
always cease by limitation, but may continue for months or years 
after the child is born. 

In the same manner and for similar reasons, the indirect conse- 
quences of an embarrassed circulation during pregnancy which 
incidental disorders of a PP ear ni dropsical, hemorrhoidal, and varicose 
circulation. conditions, are frequently entailed upon women. 

And there is no doubt that these troublesome sequelae do often 
affect the internal as well as external surfaces and structures. 

In this second column, which is devoted to the derangements of 
the nervous system which are incident to pregnancy, you will ob- 
serve that the mind, as well as the body maybe 
implicated. Indeed it sometimes happens that 
the mental disorders which accompany and which follow pregnancy 
are altogether the most prominent. In some cases they are most 
pronounced directly after conception ; in others they come about 



52 THE DISEASES OF WOMEN. 

the period of quickening; and in others still, they develop very 
decidedly as term approaches. It is in the lat- 

Metro-cerebral disor- , i'x' 'ii.lix.li ±. 

ders ter class of cases especially, that the most serious 

conditions of mental derangement may extend 
beyond the period of pregnancy and result in puerperal insanity. 
Even where this effect does not follow directly, the less acute 
forms of mental disorder may come from an acquired predisposi- 
tion on account of pregnancy, and declare themselves long after 
the period of gestation has terminated. The whole subject of 
utero-mental pathology is intimately related to the influence which 
preo-nancy may have upon the subsequent health of women. 
As a clinical rule, the diseases of the sensory and motor nerves 
which occur during gestation are self-limited, 
Affections of the ce- uke those of diphtheria. Exceptionally, how- 

rebro-spinal nerves. L l J 

ever, they appear to be fastened upon women 
because of weakened and enfeebled conditions of the general sys- 
tem, that have been induced or perpetuated by lactation, or perhaps 
by a too early and copious return of the menses while she is yet 
nursing her child. 

Although, as a class, the disorders of digestion that- occur during 
pregnancy are very frequent and distressing, 

Disorders of digestion. ^ " 

yet they usually disappear at or betore term. 
The consequence is, that their usual consecutive effects are neither 
very lasting nor serious. The structural changes that are proper 
to the liver in the form of fatty deposits may continue during 
lactation, but, except in rare cases, they are finally disposed of 
without compromising the health of the subject in the future. 
The same is true of the incidental affections of the urinary sys- 
tem, the most prominent of which is the develop- 
Disorders of the un- ment f Brio-ht's disease, with its accompanying 

nary organs. rt . . 1 ./ a 

albuminuria, uraemia and a tendency to eclampsia- 

However formidable these accidents of pregnancy, they are almost 

always self-limited, and can therefore hardly be said to increase 

the predisposition to the special diseases of non pregnant women. 

Unless they are connected with cardiac lesions of structure or 

function, or of both, pulmonary disorders that 

Pulmonary disorders. . .,..,„ 

may occur at this time have no especial signifi- 
cance. With these exceptions they are more apt to be improved 
than aggravated by the development of the gravid uterus. 



GENERAL PATHOLOGY CONTINUED. 53 

(2.) Of the Diseases that are cured by Pregnancy. — It is not 

unusual for a woman to date her pregnancy from the time in which 

she experienced a marked improvement in her 

^e vis mediatrix of health> Nervous, hysterical and dyspeptic dis- 

pregnancy. J ./ i i 

orders may sometimes be suspended or disposed 
of in this way : but the diseases which are most likely to be ben- 
efited because of conception are the different forms of ovaritis, 
dysmenorrhea, chronic metritis and prolapsus uteri. 

I think that in our day it is generally conceded that the effects 

of pregnancy upon the development of phthisis 

Effects upon phthisis. , ° ,. ". . . , . „ 

pulmonahs, is that, although for a time it may 
be retarded, yet afterwards its progress will be hastened. This is 
especially true in case of rapid child-bearing. 

(3). Of the Diseases that Co-exist with Pregnancy. — This division 
includes carcinoma of the cervix-uteri and of the labia, intersti- 
tial and sub-peritoneal fibroids of the uterus, 
influence of pregnancy. tumors, ulceration of the os-uteri, and 

upon co-incident disease. ' 

pelvi-peritonitis. The tolerance of these com- 
plicating affections and foreign growths, and their reciprocal influ- 
ence upon pregnancy, would make a curious chapter in the clinical 
history of utero-gestation. 

The growth of a malignant disease like cancer, or of a benign 
tumor, like a fibroid, may be retarded while the 

Influence upon ovarian foetus . developino; j n u [ eY0 , But their course 

tumors, etc. l ^ 

is likely to be more rapid after term. An ova- 
rian cyst may cease to grow, or it may be removed during preg- 
nancy, as has been done by Spencer Wells and others, with no 
very great risk to the mother, and still less to her offspring. The 
uterine ulceration may disappear spontaneously as the neck of the 
womb is developed, or the peritonitis may become latent until the 
puerperal period has arrived. 

But either of these morbid contingencies may act as a predis- 
posing or an exciting cause of abortion. In short the reciprocal 
tendency of things when these affections co-exist with pregnancy 
is that the first of these two conditions must be practically 
arrested and disposed of, or the second must come to an end. 

In conclusion I ought to tell you that the mere fact that most 
of the diseases of pregnancy are self-limited, does not give exemp- 
tion from them in the non-pregnant condition. For, as a patient 



54 THE DISEASES OF WOMEN. 

who has once had an attack of croup, of pneumonia, of enteritis, 
mu ,. „ or of epilepsy, is all the more likely upon 

The diseases of preg- l 1 J ' I v 

nancy may recur in theexposure to have a second attack, so a woman 
non-pregnant. w j lQ j^ Sll ff erec j during- pregnancy from either 

of the diseases named in the table on the black-board, will be ren- 
dered more prone to it than if she had never conceived. This 
remark applies with especial force to the diseases of the uterus 
and its appendages. 

Nor should you forget that, while pregnancy is a powerful pre- 

disponent of the diseases that are peculiar to women, menstrua- 

.. . tion may afterwards act as an exciting- cause 

Menstruation may be J o 

the exci ing cause for thereof, so that, practically, it is as if gestation 
thisxeiapsH. repeated itself every month. It is not strange, 

therefore, that, under these conditions, the conservative powers 
of Nature are so entirely overcome, and the uterine cachexia is so 
often developed. 



LECTURE III 



GENERAL PATHOLOGY — CONTINUED. 

4. Parturition.— Effects of, on the nervous system; in primiparas ; do. multipara; 
traumatic lesions of. 5. Puerperality.— Diseases of ; uterine involution, results if 
defective; laceration of the cervix as a cause of post-puerperal diseases; the ca- 
chexia. 6. Lactation.— A necessary condition of uterine retraction, and a natural 
prophylactic of post-puerperal disease; effects of non-lactation in abortion. Case. 
—Why nursing is prophylactic of uterine disease ; weaning may be either harmful or 
salutary; effects of undue lactation. Case. 7. The Climacteric— The diseases of, 
are plethoric, anaemic, or nervous ; the class of affections that are caused by this crisis, 
those that are cured by it, and those that co-exist with. Post-climacteric affections. 

IV. Parturition. — In the order that we have chosen, parturi- 
tion, or labor, is the fourth epoch in the life of a woman. Its 
relation to gynaecology is peculiar and important, for it puts an 
end to the period of pregnancy and a limit to the diseases that 
pertain especially to that function, of which, indeed, it is the 
turning point. 

Labor is related to the diseases of women in two especial ways, 
(1) through the shock and strain to the nervous system, and (2) 
through the traumatism of the maternal passages. 

The nervous tension to which every pregnant women is subject 

in a greater or less degree, culminates in the act 

Effects on the nervous f parturitioili This is true, whether she goes 

system. L ' *= 

to term or not. For the extrusion of the ovum 
necessarily involves a drain of nerve force, and a shock, also, it 
the labor is premature, or the circumstances attending it are pecu- 
liar. Although our neurologists are not always careful to remem- 
ber it, the seeds of special forms of nervous disease are often sown 
in child-bed. 

First labors are especially obnoxious to this charge. Naturally 
enough, with the resistance of parts that have 
never been dilated or properly developed for the 
performance of this function, the degree of suffering will be pro- 
portionately increased. Here the strain is usually more prolonged 
and severe in its effects. Moreover, in the great majority of cases, 
the young wife enters upon this terrible ordeal without an ad- 

55 



56 THE DISEASES OF WOMEN. 

equate idea of what it involves or includes, except that, after 
passing through purgatory, she will, or may, become a mother. 
There is a tradition which holds that among savages women do 
not suffer in childbirth ; and there are those who 

A traditional fallacy. . • /. i ..... 

insist that it the women in civilized society could 
live in a more barbarous or " natural " manner, they also would 
be exempt from the contingencies of labor. But lioberton 
has shown that this half-truth is not worthy of credence. The 
fact is that, if ignorance and a lack of care when their children 
are born, the absence of almost all the civilizing influences of 
home, of fresh air, proper diet and cleanliness, could give exemp- 
tion from the wear and worry of bringing their children into the 
world, and from the diseases that may and do follow, our hospitals 
and dispensaries for women would be very much crippled for the 
means of clinical illustration. And what is true of the clinics is 
true of the community. 

But you are not to infer that, in second and subsequent labors, 

there is an immunity from these nervous sequelae. 

Effects in multiparas. _ , n , . 

rwery woman, whose first labor was very pain- 
ful and protracted, and accompanied b}^ convulsions, haemorrhage, 
after-pains, or even a broken breast, dreads a repetition of her 
former experience. And more than this, she may have such a 
horror of it, that through fear of becoming pregnant again, her 
subsequent health may be so shadowed and modified as to predis- 
pose her to the most intractable nervous diseases. The experienced 
physician would as soon think of treating valvular disease of the 
heart without inquiring if his patient had ever had the rheuma- 
tism, as of prescribing for these nervous disorders in multiparas 
without any reference to the lying-in as a factor in trieir produc- 
tion. You will observe that my invariable habit in these cases, 
no matter if they have had a dozen children, is to go back in my 
inquiries and learn all that I can of the parturient history of the 
patients that are brought before you. 

The traumatic contingencies of labor give rise to a class of surgical 
affections that are practically unknown in women 

Tffln in <\\ if* losion 5 * 

who have never been pregnant. Among these 
diseases are lacerations of the recto-vaginal septum, the vesico- 
vaginal septum, of the uterine cervix, and of the perineum, sub- 
involution of the uterus, and prolapsus of the womb, the vagina, 



GENERAL PATHOLOGY CONTINUED. 57 

the bladder, and the rectum. Even where none of the soft parts 
are torn during delivery, the bruising and enormous distention of 
them, often results in lesions of structure and of function that 
have a lasting effect upon the health of women. 

V. Puerperality. — The puerperal state includes a period of 
three or more months, beginning with the close of labor. The con- 
dition of a woman who has just been delivered is beset with con- 
tingencies that may either directly or indirectly implicate her 
health, and perhaps imperil her life. In my special course on the 
puerperal diseases we have studied the various causes which in- 
duce disease during the lying-in, and their special diagnosis and 
treatment; and I need not, therefore, consider them now. 

It must suffice to remind you that, as a rule, (a clinical rule, to 
which there are exceptions,) most of the dis- 

limited 868 ° f ' ^ S6lf " eases ot ' tne puerperal period are self-limited, 
providing, of course, that they are not improp- 
erly treated. We have a good illustration of this fact in the case 
of puerperal paralysis which you have seen in our hospital wards, 
and which, like cases of diphtheritic paralysis, has shown a very 
decided disposition to get well of itself.* 

There is, however, one condition of puerperal convalescence which 
is indispensable to a perfect recovery from any and 
all of the diseases of childbed. That condition 
is the proper involution or shrinkage of the uterus after delivery. 
Whatever interferes with this physiological process may bring a 
train of consequences that shall last the patient as long as she lives. 
For the retrograde metamorphosis of the uterine structures after 
labor is quite as important as the changes that occur in the womb 
during gestation. 

A moment's reflection will convince you that the requisite invo- 
lution of the uterus concerns each and all of its 

ut C erus erDS thG Gntire various tissues ; and tbat lf H is defective, either 
the lining membrane of the womb, its muscular 
or its cellular tissue, or its peritoneal envelope, or perhaps all of 
them, will very likely become permanently diseased. This is 
the way in which the various forms of metritis are often entailed 
upon women. At my last clinic I showed you a case of exfolia- 

* De la paralysie diphtherique. Recherches cliniques sur les causes, la nature et le 
traitement de cette affection. Par Maingault, Paris. 1860. 



58 THE DISEASES OF WOMEN. 

tive endo-metritis following an abortion at the fourth month, in 
which, you remember, that, although six months had elapsed 
since the accident, we found the uterus to measure four and one- 
half inches in depth. 

My own experience has taught me that an arrest of the proper 
involution of the puerperal uterus is a fertile 
iunon CtS ° f sub " inv °" source of the pelvi-peritonitis and pelvic cellu- 
litis that so often complicate other affections, as, 
for example, sub-acute and chronic ovaritis, cystitis and the differ- 
ent forms of uterine displacement, more especially flexions and 
versions of the organ. 

The fact that in a majority of cases sub-involution is preceded 
by endo-metritis, and that, especially in its 

Puerperal endo-metri- catarrhal d py8emic . f orms , this lesion is likely 

tis and sub-involution. l 7 ^ J 

to .extend through the Fallopian tubes to the 
peritoneum, illustrates the proneness to a complication of these 
disorders which may perpetuate itself. There is no doubt that 
under these circumstances the defective folding of the womb upon 
itself constitutes a veritable predisponent of uterine disease. 
You are, perhaps, aware that Dr. Emmet ascribes the occur- 
Laceration of the cer- rence of sub-involution of the uterus to lacera- 
vix a cause of. tions of the cervix. He says : * 

" It is believed that future observation will establish the fact 
that, as a rule, the involution is first stayed, and then fault}^ nutri- 
tion occurs as a consequence of some injury received during the 
progress of labor. To the occurrence of laceration of the cervix, 
and to the formation of cicatricial tissue in the vagina, and to the 
displacements of the uterus, by all ot which the circulation would 
be obstructed, we mubt, in some cases, attribute the continuance 
of an undue size of the uterus long after a reasonable time has 
elapsed since delivery." 

On the next page the same author states very emphatically that 
" for many years past he has met with few or no cases of sub- 
involution which were not due to laceration of the cervix." 

Without accepting this view of the etiology of defective invo- 
lution of the uterus in its fullest extent, there 
Effects of cervicaiiacer- ig no quest i n that such lacerations will often ac- 

ation. n i • 

count for the erosion, the europium, or cvers:o:i 
of the cervical mucous membrane, the cervical leucorrhoea, the 

* The Principles and Practice of Gynaecology, by Thos. Addis Emmet, M.D., 1879, p. 443, 



GENERAL PATHOLOGY CONTINUED. 59 

cystic degeneration of the mucous follicles in the substance of the 

cervix, and even for the follicular disease of the throat, and of the 

mucous membranes generally, which we find in chronic cases of 

uterine disease. "We shall consider this subject in its proper place 

when we have a clinical case of this kind upon the table for study. 

Apropos of the importance of securing the proper contraction 

of the uterus within the first ten or twelve davs 

Effects of mconsider- after delivery, I must caution you against the 

ate counsel. . 

mischievous habit of allowing the lying-in woman 
to quit her bed within the first day or two after the birth of her 
child, and of leaving her without the proper support of the well- 
applied binder. It is nonsensical to say there is no analogy for 
these precautions elsewhere in nature. There is no analogy in 
nature for the use of a bath-sponge or a pocket handkerchief; 
and such arguments are silly in the last degree. Moreover, 

when a physician who is in general practice ad- 
>'edic,i experience { }[ patient to sit up and nurse the child 

may need to be qualified^ * t 

in a couple of hours after it is born, and to get 
up and go around her room the next day, and she does not become 
very ill or die in consequence, he does very wrong to conclude that 
his plan of treatment, or of mal-treatment, is in all respects the 
wisest and best. For within a very few months, or years at far- 
thest, the gynaecologist will be at work to repair the injuries that 
he should have prevented. 

It is another of those harmful half-truths which holds that 

women in the lower walks of life can get up and 

go to work directly after childbirth with impu- 
nity. Place a hundred such women on our table, one after another, 
pass the uterine sound very carefully, and tell me if the depth of 

the womb is not considerably increased. Ques- 

A clinical test. . . 

tion them c Losely and answer it the great majority 
of them have not had menorrhagia, prolapsus, and a uterine leu- 
Qorrhoea ever since the child was weaned, if not from the date of 
its birth. There is no doubt in my own mind that this kind of 
careless and improvident advice is a prominent factor in the com- 
parative increase of uterine affections during the last fifty years. 
A large share of them are post-puerperal, and avoidable. 

Puerperal pyaemia, which is chronic from the outset, is apt to 
entail a predisposition to suppurative inflammation, especially in 



60 THE DISEASES OF WOMEN. 

scrofulous women. This fact has a clinical significance and a 
wider bearing among weak, delicate, scrawny 

The puerperal cachexia. , . .. P .. " . , . 1n 

and cachectic mothers than is generally supposed. 
Indeed, the puerperal cachexia perpetuates itself in this form in a 
considerable share of our cases. Pelvic abscess, suppurative peri- 
tonitis, pulmonary and hepatic abscesses, chronic bronchitis, and 
infract able forms of catarrhal inflammation, may have their root 
in this remote cause, and must be treated accordingly. 

VI. Lactation. — Apart from moral reasons why, if possible, 
every mother should nurse her own child, which reasons are hack- 
neyed enough, there is a physical argument which renders it 
indispensable that she should do so. For, in its largest sense, 
the function of lactation includes something more than the mere 
nourishing of the offspring. 

The application of the child to the breast is the most natural 

and necessary stimulus for the post-par turn con- 

The natural stimulus traction f \h e uterus. In a reflex way the 

for uterine retraction. # _ J 

frequent and habitual nursing of the infant is 
one of the best prophylactics of the puerperal diseases, for it is 
the means of emptying the womb of all debris and discharges that 
would putrify if they were retained. This tonic contraction is 
the best safeguard against septic and pyemic absorption, and also 
against an inflammation of the uterine tissues. 

Although in exceptional cases the secretion of milk may begin 
as early as the fifth month of pregnancy, one reason Avhy the puer- 
peral inflammations and fevers are to be dreaded in miscarriages 
is, that we cannot put the child to the breast in order to secure 

the proper uterine contraction. This contrac- 

Effects of non-lacta- ti ig the firgt gt towards the llorm al ilivolu- 

tion in abortion. L 

tion of the organ, and if it is not taken there is 
an arrest of diminution in size, form and weight, and it very soon 
becomes subject to disease. Its walls become hypertrophied, in- 
stead of being lessened by absorption, and its lining membrane 
congested and inflamed. This soon gives rise to chronic metritis, 
with its inevitable accompaniments of menstrual haemorrhage, pro- 
lapsus, and leucorrhcea. We had a case recently in our clinic 
that will serve as an illustration. 

Case. — Mrs. S., aged 26, had a miscarriage at the fourth month 
of her first pregnancy, five months ago, in consequence of which 



GENERAL PATHOLOGY CONTIMUED. 61 

she was confined to her bed for six weeks. The menses were very 
irregular and copious, with bearing-down pains when standing or 
walking, with great weight in the pelvis. During the monthly 
flow this weight and pressure are so increased that she is obliged 
to keep her bed most of the time. This was her first visit to the 
clinic. She had been cauterized for some time for uterine 
ulceration. 

The attention of my sub-class was called to the prolapse of the 
uterus, the total absence of cervical laceration and of ulceration, 
the redness of the mucous membrane lining the cervix, the slight 
uterine epistaxis, and the increased depth of the womb, which 
measured four and a half inches. The points made were, that in 
this case, certainly, the defective involution could not have de- 
pended upon a laceration of the cervix during labor, (as Emmet 
insists) ; and that the metritis, menorrhagia and the prolapsus were 
the unavoidable sequences of the non-involution of the womb. 

It may interest you to know that in this case the persistent use 
of secale cornutum 3, three times daily for six 

Secale cor. in. 

weeks, reduced the depth of the uterus to three 
and a half inches, by actual measurement, and relieved her entirely 
of the prolapsus uteri. 

But there are other reasons why a proper performance of the 

function ot lactation, is prophylactic of uterine 

Why nursing is aval- disease> The fact that whi l e a WOlUail Suckles 
uable prophylactic. 

her child she does not menstruate unless she con- 
tinues to do so for an unreasonable length of time, is very well 
known. The result of this arrangement is to relieve the uterus 
and its appendages of the menstrual congestion, which would have 
a mischievous effect upon the post-partum involution that is taking- 
place meanwhile. The afiiux of blood to the mammary glands is 
therefore derivative, substitutive and salutary. 

Indirectly also, by delaying the return of the menses, nursing 
usually prevents a recurrence of conception before the normal 
puerperal changes in the womb are completed. For a season, 
and for a good reason, it holds both these functions in abeyance. 

Non-lactation is therefore injurious to the health of the mother 
by inviting a premature appearance of the 

^ Weanin g maybeharm- menseSj , md ^ by increas i ng t he risks of tOO 

rapid child-bearing. Either of these results may 
predispose her to uterine disorders that will be very difficult of 



62 THE DISEASES OF WOMEN. 

cure. And, when you consider that quite a proportion of mothers 
iii fashionable life are in the habit of turning away their babies 
on the slightest pretext, you will realize that a failure in the 
performance of this function is not only prejudicial to the welfare 
of the offspring, but also and very often to that of the parent. 

There are cases, however, in which it is wrong and harmful not 

to wean the child, as, for example, when the drain upon the 

mother's strength can not be borne with safety; 

when weaning is nec- whenthemeil ^ es have b r established, and 

essary. > ' 

return with regularity and copiously; and 
when another gestation has undoubtedly begun. If nursing is 
persisted in when there is menorrhagia, it is like burning a candle 
at both ends, and no one can say how long the woman's strength 
may hold out. If she is pregnant again, and does not put her 
child away from the breast, she will be very likely on account of 
the mammary irritation to have an abortion, to suffer an inter- 
ference with the development of the gravid uterus, or to ruin the 
health of the foetus in utero. 

We must guard against the effects of undue or over-lactation, 

for while in general we should encourage the 

Undue lactation. , i -i t -, ;• i 

mother to nurse her child, it may sometimes be 
necessary to caution her against continuing the practice for too 
long a period. The ill effects of this habit are various. It may 
o-ive rise to functional and organic disease of the womb, to Sub-ill VO- 
lution, passive menorrhagia, mental, nervous, and dyspeptic dis- 
orders, anaemia and dropsical conditions, recurrent epilepsy, 
chorea and hysteria, dimness of vision, and reflex disorders of 
various kinds. 

If these consequences were self-limited and certain to end with 
the taking of the child from the breast, I would not pause to 
speak of them in this connection. But they are more lasting and 
persistent, especially when the practice has been repeated with sev- 
eral successive children. Some of you remember a case in point, 
which was that of a poor woman who came to 
my clinic, and who, within the space of ten 
years, had had eight children. She had nursed four of these 
from twelve to fourteen months each, one of them for fifteen 
months, and the other three had died when they were only a few 
months old. So that, as her story ran, although she was only 



GENERAL PATHOLOGY CONTINUED. 63 

thirty- live years old, and had been married but ten years, yet 
daring that brief period she had nursed a baby for about eight 
gears! 

VII. The Climacteric. — This is the last act in the Dhvsioloff- 

ical drama of a woman's sexual life. It is beset with vicissitudes 
that are commensurate with the importance of the function which 
it limits and terminates. A careful study of the influence which 
the " change of life,''' as it is commonly called, exerts upon the 
health of women is indispensable to you as students of gynae- 
cology. For this is indeed a " critical period.'" 

The disorders which are especially incident to this period have 
, their root in one of three conditions of the ueii- 

General qualities of < 

the climacteric disor- era! system, and for this reason may be classed 
as plethora, anaemia, or nervous. 
There is a plethora from which women suffer at this time, 
although thev may not have been subject to it 

The plethoric troubles. , » y . , .- "-, 1 . „ 

before, which is due to the suspension of an 
habitual discharge, and the stoppage of a drain that, for thirty 
years or more has weakened the blood and prevented a repletion 
of the vessels and an increase in the proportion of the red cor- 
puscles. This plethora predisposes them to various forms of 
local congestion and inflammation. But, you should remem- 
ber that a tendency to hyperemia in a woman at the change of 
life, does not necessarily increase the risk of inflammation of the 
uterus and its appendages as it would have done before the cessa- 
tion of the monthly flow. Its principal effect is to involve those 
organs which are not especially connected with the generative 
system, as for example, the brain and spinal cord, the heart and 
lungs and the stomach, or some part of the digestive apparatus. 
AVe recognize this condition of plethora in the flushed face, the 
headache, the vertigo, the dullness of the intellect which often 
amounts to a pseudo-narcotism, the anxious look, a tendency to 
local perspiration, and the restless, discontented, dissatisfied 
behavior of the patient. The pulse is usually full, but some- 
times it is feeble and thready, and there often is a decided tend- 
ency to haemorrhage. 

The climacteric anaemia is really a species of 

The anemic troubles. . 

chlorosis. j_ he condition is the opposite of that 
which we have just described. The blood is deficient in red 



64 THE DISEASES OF WOMEN'. 

globules, the vessels are not turgid, the pulse is weak and irregu- 
lar, the skin is ashy, sallow, and of a waxy or dirty-white hue. 
The anaemic murmurs, the cardiac symptoms, the digestive 
derangement, and the capricious appetite of chlorosis are often 
present. Not unfrequently there is a dropsy of the cellular 
tissue, or within serous cavities, that is very difficult to cure. 
Sometimes this latter condition is so pronounced as to remind one 
of what Grauvogl styles the " hyclrogenoicl constitution." 

The nervous type of disease at this critical period may be hys- 
terical, in which case it is a prolongation of 

The nervous troubles. , . . , , ,.,, 

what was incident to menstrual hie, or it may 
be altogether new and peculiar to the menopause. The latter is 
what Raciborski styles a " nervous plethora."* This form of 
complication is most pronounced in those who are naturally 
nervous and excitable, and in those who have been compelled by 
circumstances to undergo a great deal of worry and to carry more 
than their share of mental weight and anxiety. It often happens 
that a woman will pass through the child-bearing period, with 
all of its sufferings, cares and responsibilities, in comparative 
health and comfort, only to break down and tc become a nervous 
wreck at the climacteric. 

Bearing these general facts in mind you will be prepared to 
understand and to appreciate the kind and character of the dis- 
eases which are liable to recur at the change of life. The pre- 
dominence of either of these types at this particular turn in the 

clinical history of woman, develops a class-bias 

which complicates all of the disorders to which 
she is liable, whether they are sexual or not. As with puberty, 

so with the climacteric ; there are the diseases 
Diseases cawed by w hich are caused by this crisis, those which are 

cured by it, those which co-exist with it, and 
those that follow it. 

The affections that are caused by the climacteric are of the most 
varied character, and, as I have just hinted, are many of them of 
the non-sexual order. They include menorrhagia, irregular men- 
struation, epithelioma, leucorrhoea, haemorrhoids, dyspepsia and 
the vomiting of mucus and of blood, flushings and local perspira- 

*Traite de la Menstruation, ses rapports avee I' Ovulation, la Feeundatior, etc., par A. 
Raciborski, Paris, 1868, p. 267. 



GENERAL PATHOLOGY CONTINUED. 65 

tions, cardiac, intestinal and hepatic disorders, gnawing pains in 
the stomach, spinal, intercostal and abdominal neuralgia, colic, 
nervous irritability, hysterical narcotism, insanity, chloro-span- 
temia, asthma, paralysis, and .apoplexy. 

The change of life often cures or puts an end to chronic metri- 
tis, to the further growth of uterine polypi and 

r^jcfiQcpc CiULirpci t")V it 

fibroids and to the various uterine displacements, 
to leucorrhoea, hysteria, to a menstrual ataxia, to mammary pains, 
and to sufferings in the rectum and the bladder, which have de- 
pended for a cause upon the recurring menstrual congestion. 
Amenorrhoea, dysmenorrhoea, and all kinds of catamenial disorders 
cease by limitation when this crisis has really come. 

The various neoplasms of the uterus, as fibromata, polypi and 

cancer may co-exist with and survive the menopause. As a rule, 

those diseases which run their course during this period, and which 

continue after it, are either modified and prac- 

Jteezses that co-exist ticaUy disposed of by it? or they develop more 

rapidly when the menses have finally ceased. 
Ovarian cysts, and uterine and ovarian cancer are often hastened 
in their progress by the climacteric. And, so, likewise, are the 
various forms of tuberculosis, and of chronic, hepatic, renal and 
cardiac disease. 

Beside the proneness of some of the diseases of puberty to 
return at the climacteric, as, for example, cer- 

fectTonf 111 ^ 6 ^ af " tain skin and bowel affections, and phthisis, there 
are other disorders that are likely to follow it. 
Among them are chronic headache, deafness, insomnia, insanity, 
apoplexy, the various forms of paralysis, and the development of 
cancer of the uterus and of the mammary glands. 



LECTIJEE IV. 

PHYSICAL DIAGNOSIS IN GYNAECOLOGY. 

1. Inspection.— The four varieties of ; abdominal do. of the external parts ; do. by the 
uterine speculum; do. by the forcible eversion of the rectum. 2. Mensuration.— 
Modes of applying. 3. Palpation, abdominal and vaginal, cases to which the for- 
mer is applicable; the "touch" per vaginam ; conjoined manipulation and when it is 
of use ; the uterine touch and the conditions requiring it. 

Before we begin the study of any particular affection, I think 
it best to direct your attention to the rational signs that belong 
to the diseases of women, and the proper method of eliciting them. 
With the addition of internal exploration, these methods are 
practically the same as those which are employed in the diagnosis 
of the diseases of the heart and lungs. This table on the black- 
board includes the various methods of physical exploration which 
may be used in the diagnosis of the diseases of women : 



1. 


Inspection. 


2. 


Mensuration. 


3. 


Palpation. 




a Abdominal palpation. 




f By the vagina. 



By conjoined manipulation. 
b The " Touch:' <j By the rectum. 
By the bladder. 
[By the use of the sound. 

4. Percussion. 

5, Auscultation. 

1 . Inspection. — The examination by the sight is resorted to in 
four different ways ; [«] To the external abclo- 

Varieties of inspection. r7 _. ,11 ,i • -1 i • v 

men ; \U] directly by the unaided eye 111 diseases 
of the external genitals; [c] indirectly to the vagina and uterus, 
by means of the speculum ; and [d] by the forcible eversion of the 
rectum. 

Abdominal Inspection. — In inspecting the abdomen the patient 
should either lie upon her back or stand erect. In many cases it 
is a o;ood rule to place her in both of these positions successively. 



PHYSICAL DIAGNOSIS IN GYNECOLOGY. 



67 



This mode of examination detects any abnormal projection, such 
as the tumor formed by the gravid uterus at or after the fifth 
month, a considerable enlargement of either of the ovaries, fibroid 
tumors, an excessive accumulation of urine, and ascites. It is not 
an accurate means of exploration, for it often happens that abdo- 
minal tympanitis may cause such a projection of the parietes as 
shall simulate the tumors of which I have just spoken. 

Inspection of the External Genitals.— Direct visual inspection is 
resorted to in diseases affecting the vulva, as, for example, in vul- 
vitis, vaginitis, pruritus, abscess of the labia, abscess of Duverney's 
o-land, vulvar enterocele, and hematocele, and also in urethritis 
and vascular tumors of the meatus, gonorrhoea and chancre, cyst- 
ocele, rectocele, and external displacements of the uterus. This 
method of examination, however disagreeable it may be, is some- 
times indispensable. It should be made in a strong light, and 
in order to prevent a necessity for its repetition, should be as 
thorough as possible. Here is a speculum for the labia that is 
sometimes useful. 




Fig. 1. Wire Speculum for the Labia. 

Inspection by the Uterine Speculum. — By the aid of the uterine 
speculum, which is a very old instrument, the neck of the womb 




Fig. ~. Ferguson's Tabular Speculum. 

and the wall of the vagina are exposed to our view. Here, upon 
the table you will find a variety of specular, from which we must 



68 THE DISEASES OF WOMEN. 

select the most appropriate for the ease that is under treatment. 
The simplest, and cheapest, and one that will answer for ordinary- 
practice, is Ferguson's tubular speculum, which is made of a tube 
of glass that is coated with quicksilver, covered by India-rubber, 
and afterwards varnished. There are two forms of this instru- 
ment. 





Fig. 3. Ferguson's Modified. 

In either of its forms this speculum has, however, such a limited 
range of application that it will not do to depend upon it exclu- 
sively. Indeed there is no speculum in the form of a tube that 
fills as many indications as the valvular instrument. And I recom- 
mend you either to buy Cusco's duck-bill speculum, or some mod- 
ification of it. Here it is: This 
instrument, which was devised by 
a prominent oculist in Paris, has, 
like the obstetric forceps, been 
changed and modified a great many 
times, but without being materially 
improved upon. For all the prac- 
tical purposes to which a bivalve 
speculum can be applied, the old 
Fmfl. cusco's Duck-bill Speculum. form is the best. I advise you not 
to buy one that is too short, as some of them are ; for I have 
found it a g-ood thing to have a speculum which 

The best speculum. _ °, .,_ i , 

can be used either as a long or short one, just 
as I have found it best to supply myself with the long obstetric 
forceps which can be used at the inferior strait also, when it is 
necessary. You can make use of a long Cusco as a short instru- 
ment, if you need to: whereas a shor* ov& would not always 
answer your purpose. 

It is a good rule in gynaecology, and in general surgery, not to 
multiply or to load yourself down with instru- 
ments. If one speculum will fill a numb©- 1 * of 
indications, you do not need to be burdened with half-a-dozen 
sizes or as manv kinds of the same instrument. 




PHYSICAL DIAGNOSIS IN GYNECOLOGY. 69 

I also advise you not to select a bivalve speculum in which one 
blade is shorter than the other, for if you become expert in the 
use of this instrument, and are careful to adapt 
it properly, you will do better work if the blades 
are of equal length. The reason is, that in the latter case the 
speculum is applicable to all kinds ol cervical deformities and 
deviations, while in the former it is not. 

Nor should you select one in which the upper blade is divided, 
for when it has been passed, and the blade separated, the roof of 
the vagina will be very apt to fall between them and to obstruct 
the view. This is the objection to Nott's Nelson's, Meadows', 
Graves', Bozeman's, Jenks', Ball's, and also to Hough's five-blade 
speculum . 

Here is a specimen of my friend Nelson's instrument, which, 




Fig. 5. Nelson's Speculum. 

when the blades are divided, in case of a redundencyot the vaginal 
tissue, will permit it to fall between them on all sides, and so 
defeat our purpose. 

Hunter's short and stubby bivalve is especially adapted to those 
cases in which the cervix is either very short congenitally, or as a 
consequence of amputation or of excessive cauterization. There 
is no practical advantage in having one of the blades cut open as 
some of these are for the purpose of passing the uterine sound, 
and for its manipulation afterwards. I shall refer to this matter 
when I come to speak of the uterine sound. 

There is no doubt that Dr. Marion Sims' discovery of the spec- 



■() 



THE DISEASES OF WOMEN. 



ulum that bears his name was one of the most important events 
in the history of American Medicine and Sur- 

Sims' Speculum. „. . , , , ., . 

gery. Ihis speculum also has been variously 
modified but without being materially improved since Sims' first 




Fig. 6. Sims' Speculum. 

used it as a perineal depressor, in making the operation for vesico- 
vaginal fistula. 

As the patient is lying upon her left side, the posterior com- 
missure of the vulva and the perineum are drawn steadily back- 
ward toward the sacrum and coccyx. The air dilates the vagina 
and by means of this wire depressor applied at its anterior portion 
the cervix is fully exposed to view, by what is practically a bi- 
valve speculum. 

As you will readily infer this speculum is specially adapted for 
use in surgical operations within the vagina. I shall therefore 
have occasion to show you how and when to use it when we come 
to the operating table. There is a modification of it however, 




Fig. 1. Dawson's Sims' Speculum. 

which adapts it to ordinary practice, and which has the advantage 
of being portable and of affording two sizes of the same instru- 
ment. This is known as Dawsons' Sims'. 

In the use of this instrument the single blade is passed over the 
perineum with its concave surface looking towards the symphysis- 
pubis. 

Here is a modified Sims', attached to a self-retaining rubber 






PHYSICAL DIAGNOSIS IN GYNECOLOGY. 



71 



harness that runs along the back and over the shoulders of the 




Fig. 8. Self-retaining speculum. 



patient. Happily, I have forgotten the name of the " modifier." 
Although Dr. Barnes has really improved upon Neugebauer's 
instrument, I have found it inconvenient and objectionable. For 
even with the greatest care in its introduction and withdrawal, 
one is very likely to pinch the vaginal folds and to hurt the pa- 
tient. 




Fig. 9. Barnes' Neugebauer's Speculum. 

As to the mode of applying the speculum, 
authorities are not quite agreed. Without 
quoting all they have said and thereby confus- 
ing your minds on this subject, I will briefly state what my own 



How to apply the 
speculum. 



72 



THE DISEASES OF WOMEN. 



practice has been. The patient is usually placed upon the back 
with the hips drawn to the edge of the bed, or, of the operating 
chair or table. We may use Wilson's chair, (Fig. 10), or Archer's 



Fig. 10. 




(Figs. 134-5-6), or Chadwick's table, (Fig. 11); but in the hospital 
you will observe that my patients are placed upon a short, firm 
table, which has been made expressly for that purpose. 
The bed or table should be drawn before a window in a strong 
direct light, for the sunlight is better than any 
kind of an artificial light, in making these ex- 
aminations. When the sky is dark and lowery, as it is to-day 



The table. 




Fig. 11. 



we can use a hand lamp for the purpose. But, as a rule, the 
flame of an ordinary lamp is so yellow as to 

The light. - 

change the complexion of the parts, and to give 
a wrong idea of the lesion which you may find. For this reason 
an alcohol lamp, or a wax or sperm candle, is altogether prefer- 
able. If you are careful to burn the sulphur first, and not to set 



PHYSICAL DIAGNOSIS IN GYNAECOLOGY. 73 

the clothing on fire, a common match will sometimes answer your 
purpose. 

Before the speculum is introduced it should be warmed and 
thoroughly anointed with lard or sweet oil, or, better still, with 
soap at the dressing table. In the hospital we use cosmoline for 
this purpose. In delicate persons glycerine is sometimes very 
disagreeable. 

Having first passed the finger in order to find the whereabouts 

of the cervix uteri, and to have an idea of its 

Mode of passing the j sensibility, and also of its mobility, the 

speculum. ' J m J _ 

speculum is introduced with its blade or blades, 
in a direction that is parallel with the labia. Entering in a line 
with the axis of the vagina, as soon as it has fairly passed within 
the vulvo-vaginal orifice, the instrument must be turned so that 
its broad surfaces shall look towards the pubis and the rectum. 
In most cases it should be expanded just before reaching the cer- 
vix. This manipulation greatly facilitates its introduction, while 
it lessens the pain, for you must remember that, except at its 
external orifice, the vagina is a flattened tube, and not a round 
one, as is generally supposed. 

In order to expose the cervix more thoroughly to view, a bit of 

soft cotton wool, or absorbent cotton, may be 

cervix. t0 CleanSe ^ wound about the end of the lon S dressing for- 
ceps. With this extemporized brush, which is 
always clean and new, we may wipe away the discharges that lie 
within and about the os-uteri. In many cases this little operation 
is best accomplished by bringing the brush into delicate contact 
with the part, and then turning it over and over, so a» to entangle 
the mucus and to take it away without injury to the underlying 
surface. 

If I may judge by the complaints of patients who have come to 

me from other gynaecologists, there is quite as 

painless withdrawal h d f { the removal of the specu- 

of the speculum. * 

lum, in order to save pain, as in its introduction. 
For this purpose there is a simple expedient which I have prac- 
ticed, and which, for twenty years or more, I have recommended 
to our pupils. It consists in turning the screw which separates 
the branches, only so far back as permits the withdrawal of the 
instrument, while it prevents their complete closure and precludes 



74 THE DISEASES OF WOMEN. 

the possibility of pinching the soft parts. If the cervix is very 
much swollen the additional precaution of keeping" the blades of 
the speculum widely separated until they can no longer grasp the 
neck of the womb, is easil} r practiced. Half the dread that deli- 
cate women have of a local examination, by the use of the speculum 
and other instruments, Avould be done away with if the doctors 
were more careful in their application and removal. And it is 
just such wrinkles as this that you will need to know at the 
bedside. 

Inspection by the Forcible Eversion of the Rectum. — In the 
year 1868, Dr. H. R. Storer, of Boston, wrote as follows:* 

' ; By passing the finger into the vagina and pressing it back- 
ward and downward over the levator ani, the rectum can be 
everted through its sphincter like the finger of a glove. This 
can ordinarily be done to a very great degree ; it can always be 
done to a certain extent. Should the sphincter be unusually irri- 
table, and spasmodically contract with violence when touched 
from below, or thus from above, it can be forcibly distended by 
the thumbs and temporarily ruptured. * * * We can in this 
manner ascertain the presence of chancre, or of chancroid, the 
character of polypi, the extent and number of internal haemor- 
rhoids, the position of the inner orifice in fist uhe," etc., with far 
greater certainty and alacrity than by the speculum, or than can 
be done in the male; while the mere eversion process, provided 
rupture of the sphincter is not necessary, is attended by very 
little pain." 

The greater difficulty of treating the diseases of the rectum in 
women than in men, and their frequent complication with uterine 
affections may sometimes compel us to resort to this method of 
inspection 

II. Mensuration. — We measure the abdomen in cases of ovar- 
ian dropsy, uterine fibroids, pregnancy, extra-uterine pregnancy 
and ascites. The measurements that are most 
frequently taken are the perpendicular, which 
extends along the linea alba from the symphysis pubis to the 
umbilicus, and thence, if necessary, to the zyphoid cartilage; the 
circular, which passes around the body at its largest girth, about 
or below the umbilicus; and the diagonal measurements, or from 
the anterior superior spinous process of the right ileum to the 
point of the last floating rib of the left side, and vice versa. 

* Vide the American Journal of Obstetrics and Diseases of Women and Children, Vol. 
I., page 71. 



PHYSICAL DIAGNOSIS IN GYNAECOLOGY. O 

I shall have such frequent occasion to illustrate this mode of 
physical exploration in my clinic, that it is unnecessary to say 
more of it at present. Strictly speaking, it is also applied to the 
measurement of the depth of the uterus by the employment of 
the sound ; but that form of mensuration will be considered when 
we come to speak of the uterine sound as an aid to diagnosis. 

III. Palpation. — There are two modes of palpation that are 

applied to the physical diagnosis of the diseases of women, viz., 

the abdominal and the vaginal. By the former, or external 

variety, the outline, size, texture, and mobility 

Abdominal palpation. _ . . 

ot abdominal and pelvic growths and tumors, 
and the presence of dropsical fluids within the peritoneum, or 
within cysts of the ovary, or of the broad ligament, are detected 
with considerable facility. 

The value of this means of exploration varies with experience, 
and with the tact that is used in its application. I recommend 
you to practice it whenever it is convenient in cases of pregnancy, 
after labor, and during the puerperal state, in order to familiarize 
yourselves with it. En passant, there is no better time for the 
l®cation and the identification of extra-uterine growths than 
directly after delivery, when the process of involution has just 
begun. 

It is of very little use to practice this hypogastric touch unless 
you are careful to apply the palmar and tactile 

A clinical hint. J p ■ _ _ \ l J . % , ^ 

surface instead of the tips of the fingers. For 
it is only by this means that you can obtain a proper idea of the 
firmness and the other physical qualities of a tumor. Moreover, 
we may sometimes gain a great deal by seizing and grasping the 
growth and closing the hand around it; and besides, this method 
is not halt so painful as that of punching the parietes with the 
ends of the fingers, as is usually done. 

The " Touch" per Vaginam. — Vaginal palpation, or the "touch," 
as it is usually styled, has the widest range of application in 
gynaecological practice, and is really of more service than any 
other mode or means of physical exploration. 

The usual method of applying it is to place the patient either 
upon the back or upon the left side, as in ob- 

Position of the patient. . . 

stetric practice. It is well, however, to vary 
the position that is chosen with the object sought for by the exam- 



76 THE DISEASES OF WOMEN. 

ination. Thus, if you desire to examine the vulva and the vagina 
thoroughly on all sides, to feel along the course of the urethra, 
to ascertain if the uterus or the bladder is prolapsed, or to meas- 
ure the length and the circumference of the cervix, (if it is not 
beyond reach) she had better lie upon her back. But, if you 
wish to know by the touch whether the womb is flexed upon 
itself, if it is high in the pelvis, to explore the posterior roof of 
the vagina, and to sweep the finger around the cervix, place her 
on her left side. In order, however, to examine the right or the 
left lateral cul-de-sac, it is sometimes best to have the patient lie 
upon the opposite side, and to use the index finger of the right or 
of the left hand, as the case may require. Where there are intra- 
pelvic tumors which affect the size and the position of the uterus, 
the bladder, or the rectum, we may find it necessary to apply the 
touch while the patient is standing erect. In the virgin the touch 
is best applied by placing the patient on the left side, with both 
knees drawn up and closely applied to each other. 

The finger, or fingers, for it is sometimes necessary to use more 

than one, should first be anointed as directed for the speculum. 

Then, the patient being covered with the bed-clothing, or with 

a sheet provided for the purpose, the index 

The use of the firmer. , . . n , . ,„ 

finger which is flexed upon itself, may be passed 
between the labia with its point toward the anus and its palmar 
surface looking backwards. Once within the vulvo-vaginal orifice, 
the necessary manipulation should be slowly and carefully made. 
The object of the " touch " as thus applied, is to note the heat 
and dryness, or moisture of the vagina, its capacity, the integrity 
of the vesico- and of the recto-vaginal walls, 

What may be learned . . , ... ...., „ . . 

from it. the size and sensibility ot the uterine cervix, 

any inequalities of its surface, the form and 
comparative size of the two lips of the cervix, the shape and 
patency, or the closure of the os-uteri,the mobility of the womb, 
and the presence of tumors in the retro-uterine pouch. Thus 
you will see that the skilful gynecologist will need to have the 
means of diagnosis literally at his finger ends. 

Conjoined Manipulation. — What is sometimes styled bi-manual 
palpation consists in the use of abdominal and vaginal palpation 
at one and the same time. While the index finder of one hand is 
within the vagina, the bladder having been emptied and the knees 
flexed, the other hand is placed upon the abdomen, and by pres- 



PHYSICAL DIAGNOSIS IN GYNAECOLOGY. 77 

sure with the tips of the fingers directed toward the superior 
strait, the pelvic organs can be readily felt around the symphysis 
pubis and between the two hands. This method of exploration 
is not, however, applicable when the patient is standing. 

This double mode of palpation is useful where the uterus rests 
very high in the pelvis: where its size is in- 

When it is applicable. _ . , . , . n 

creased as in pregnancy, sub-involution and 
hypertrophy: in case of uterine and ovarian tumors, and abscess 
of the broad ligament ; to detect the anchorage of the womb in 
cancer, or as a consequence of pelvi-peritonitis, or of pelvic cellu- 
litis ; in flexions and versions of the uterus ; and in the diagnosis 
of all kinds of retro-uterine tumors. Its application is very easy 
in thin and delicate women, and, as a rule, directly after delivery 
at term ; but it is more difficult in those who are fleshy, or who 
have never borne children. In order that it shall be successfully 
employed the patient should understand what it is that we are 
about to do, otherwise, it might happen that through fright or 
timidity the abdominal muscles would be so contracted as to 
interfere with our purpose. 

The combined touch is sometimes very useful also, as an aid in 
the diagnosis of intra-uterine growths and 

The uterine touch. l ' . . 

tumors. In this case the finger is passed into 
the uterine cavity, which permits of a tactile examination of the 
lining membrane of the womb, by which we may recognize the 
presence of granulations, polypi, fibroid tumors, and abnormal 
growths of various kinds ; and also of the conjoined examination 
of the uterine parietes and of the neighboring organs. It is 
sometimes, although not very often, of great importance to have 
the womb so under our control that w T e can examine it as thor- 
oughly and as carefully as if it were lying on the table before us. 
But, in order that the uterine " touch " may be practised suc- 
cessfully, two conditions are indispensable, (1) that the os-uteri 

be thoroughly dilated, or dilatable; and (2) 
conditions for apply- that the ^ ghall be free f abnormal 

ing it. 

attachments as to permit of its being pressed 
downward into the pelvic cavity by the hand that is upon the 
abdomen, so that the finger may be applied to its internal surface. 
Without the former, the admission of the exploring index finger 
would be impossible; and, without the latter, the retreat of the 
uterus would be inevitable. 



LECTUKE V. 

PHYSICAL DIAGNOSIS CONTINUED. 

Physical Diagnosis, continued. The three kinds of rectal touch ; manual exploration of 
the rectum, or Simon's method; the "touch" by the bladder: the touch by the sound, 
why and when it should be employed; directions as to time and mode of its introduc- 
tion, the position of the patient; the conjoined use of the speculum and the sound, a 
rare Case. Sim's elevator as a sound. The sound in fibromata ; do. instead of the 
tenaculum. 4. Percussion— Object and range and use of, in pregnancy, ascites, ovar- 
ian dropsy, and uterine tumors. 5. Auscultation— Use and range of, cases to which it 
is adapted. 

At the close of my last lecture I had not finished the subject of 
palpation, as one of the modes of physical diagnosis in the dis- 
eases of women. It, therefore, remains to speak of the " touch" 
as it is sometimes applied through the rectum, the bladder, and 
by means of the uterine sound and the probe. 

lite Rectal " Touch." — There are three kinds of rectal touch 
that we may find of service in our specialty: (1) the introduc- 
tion of the index finger into the rectum; (2) the combined appli- 
cation of the finger within the rectum, and of the thumb of the 
same hand within the vagina; and (3) the passage of the hand 
into the bowel, for the purpose of a deeper and a more thorough 
exploration of the cavity and the contents of the pelvis. Neither 
of them, however, can take the place of the vaginal touch to 
which, indeed, they are complementary. 

Of course the rectum should first be emptied of faecal matter. 
The choice of the finger that is to be intro- 
duced is quite as important as is the choice of 
the hand in the performance of podalic version. Do not forget, 
therefore, that you are to select the index finger whose palmar 
surface, when it has been passed, will look toward the vagina. 
For this is the side of the bowel that you will need to explore, 
and through which you mast learn whatever you can of the posi- 
tion and condition ol the pelvic organs. 

This simple touch per rectum is especially useful in the detec- 
tion and diagnosis of posterior and lateral displacements of the 
uterus, and of retro-uterine and faecal tumors, prolapse of the 



PHYSICAL DIAGNOSIS CONTINUED. 79 

ovaries, and also in ulceration, paralysis and perforation of the 

anterior Avail of the rectum. In young girls it is sometimes 

resorted to instead of the examination per vaginam. 

. This mode of the touch may also be conjoined with abdominal 

palpation. For, by external pressure the uterus 

The recto-abdominal fte be de t descend and to be held SQ 

touch. _ ' 

that the internal rectal exploration may be more 
extensive and thorough than it could otherwise be. This expe- 
dient also enables us to note the changes in the position of the 
womb which have been caused by the morbid development of the 
rectum. 

Some of the members of the class will recollect the examina- 
tion that I recently made in their presence, of a 

The recto-vesical touch. " . 

woman twenty-tour years ot age, m whom no 
trace of a womb could be found. The final, and the most com- 
plete test, consisted in passing the catheter into the bladder, and 
then, with my index finger in the rectum, observing whether I 
could touch the point of the instrument. If the uterus had not 
been congeni tally absent it must have lain between the finger and 
the distal end of the catheter, and I could not have felt the latter 
as I most certainly did. This fact was confirmed by our friend, 
Dr. Miessler, who brought the patient to my clinic. 

But the form of double touch that was practised by Recamier, 

and extolled by Tilt and others, is the recto- 

The recto- vaginal touch. . . . . 

vaginal exploration, which consists in the sim- 
ultaneous passage of the thumb and the first finger of the same 
hands into the vagina and the rectum. Ghillard prefers the first 
two fingers, the index and the medius. We may resort to this 
mode of examination to measure the thickness and density of the 
recto-vaginal septum; and, also to learn if the smaller tumors as, 
for example, a prolapsed ovary lying at the lowest extremity of 
the posterior cul-de-sac, and in this septum are sensitive, movable, 
or fluctuating. It also permits us to measure the antero-posterior 
diameter of these tumors or abscesses, as the case may be, and to 
decide whether and when it is safe or expedient to resort to sur- 
gical means for their cure. It is indispensable in the diagnosis of 
rectocele and rectal cancer, and also in some cases of laceration of 
the perineal body. Tilt recommends it for the detection and 
removal of foreign bodies lying in the recto-vaginal space. 



80 THE DISEASES OF WOMEN. 

In a paper read before the Surgical Association in Berlin, April 

13th, 1872, Prof. Simon, of Heidelberg, advised 

Manual exploration of a me thod of exploration which consists in the 

the rectum. . 

dilatation of the anal sphincters, and the pas- 
sage of the hand into the rectum. He had already practised this 
method for some years, and was very sanguine of its adaptation to 
cases in which it was impossible otherwise, to make a complete 
diagnosis of certain pelvic and abdominal tumors. You will find 
the full text of Dr. Simon's essay in the American Journal of 
Obstetrics, etc., for February, 1873. 

In performing this exploit, or expedient, the patient will first 
need to take an anaesthetic. The hand, which in its greatest cir- 
cumference must not measure more than ten inches, should be 
thoroughly warmed and anointed, and in what is called the 
"bloodless" method, the sphincter forcibly stretched with the 
four fingers of the operator's hand. In the " bloody " method, 
the anus being very narrow, its margin is enlarged by several 
notches through its cutaneous border. In rare cases an incision 
along the raphe and through the sphincter is advised. 

When four fingers have been introduced up to the origin of the 
thumb, it constitutes what Dr. Simon styles an ' •examination with 
half of the hand;" and when the whole hand and part of the 
fore-arm are passed into the rectum, we have an " examination by 
the hand, or manual examination." He says: 

" When the whole hand has been brought into that part of the 
rectum lying in the concavity of the sacrum as far up as the 
promontory, we can then introduce three, and even four fingers 
still further up and a small distance into the sigmoid flexure, 
and reach above the umbilicus without in the least injuring the 
intestines or the peritoneum, and the upper portion of the rec- 
tum and the sigmoid flexure being extremely movable, can palpate 
the whole abdomen as far as the lower edge of the kidney.* If 
all violence be avoided during the exploration of the upper por- 
tion of the intestines, and especially if no attempt be made to 
introduce the whole hand into this part, the examination is 
entirely without danger. In introducing the hand through the 
anus, however, more force is occasionally required, and is perfectly 
admissible, since neither dangerous injuries nor any damage to 
the subsequent contractility "of the sphincter are to be appre- 

*The lower point of the kidney can be reached if the thigh of the person under exam- 
ination he strongly flexed. 



PHYSICAL DIAGNOSIS — CONTINUED. 81 

hencled. If the muscle be so dila^-hle as to allow the passage of 
the hand without difficulty, or after superficial incision ot the 
cutaneous margin, no disturbance of its function is produced; if 
it be necessary to divide the sphincter, the incontinentia alvi lasts 
ten or twelve days until the wound is healed. The importance of 
such a dilatability of the anus during anaesthesia, and the possi- 
bility of safely palpating the organs of the pelvis and the abdo- 
men up to the middle of the latter cavity, the finger being only 
separated from the organs to be examined by the thin intestinal 
wall, is very evident. For it is possible, as already mentioned, 
not only to find foreign bodies in the lower part of the sigmoid 
flexure, and to extract them without injury to the intestine, but 
we can also diagnosticate diseases of the rectum, uterus, ovaries, 
and the pelvis in general, which consist in changes of shape, 
position, and consistence, with much greater certainty than by 
the former methods of examination. In examining with four 
fingers, and, better still, with the fingers of the whole hand intro- 
duced into the rectum, we can reach the fundus and anterior wall 
of the uterus from behind, grasp the ovaries between the thumb 
and the other fingers, and feel any increase in size or irregularity; 
we can, in the male, palpate the bladder up to its vertex and 
detect any diseased condition, such as stones, their size, shape, 
and number. I am convinced that, the whole hand being intro- 
duced, we can, with the fingers, by direct palpation, ascertain 
the presence of invagination, accumulation of faeces, strictures, 
etc., as far up as a portion of the sigmoid flexure, feel tumors of 
the posterior abdominal wall, the mesenteric glands, kidneys, 
and most of the other organs which are situated in the lower 
two-thirds of the abdomen or reach down as far,* and thereby 
gain most useful diagnostic aid. In two cases of ovarian 
tumor, in which I made use of the manual examination, and 
in which the result of the exploration was controlled by the 
subsequent extirpation, I accurately determined the length and 
size of the pedicle, the nature of the healthy ovary, the absence 
of adhesions to the brim of the pelvis, and, in one case, two 
fibroid tumors of the size of cherries, which were situated at 
the fundus uteri. In a case of multiple fibroid tumors, where 
I explored in this manner, I distinctly felt the site, size, and 
breadth of base of the tumors on the corpus and fundus uteri. 
In one case, I even combined a therapeutical act with the exami- 
nation, in liberating one of the fibroids of the fundus, which had 
become wedged into the pelvic cavity and could not be loosened 
by the fingers alone, from its incarceration, and pushing it with 
the hand into the abdominal cavity, where I could palpate it with 
the enlarged uterus in its whole extent. In one case of hydro- 

* Tumors of the liver, stomach, and spleen must be palpable in the same manner, if 
they reach as far down as the umbilicus. 
6 



82 THE DISEASES OF WOMEN. 

nephrosis I could distinctly ascertain that the tumor hal ao con- 
nection with the pelvic organs, which were entirely devoid of 
adhesions and allowed me to pass my hand between them and the 
tumor to the anterior abdominal wall, thus permitting me plainly 
to recognize the lower body of the hydronephrosis and its attach- 
ment at the posterior boundary of the abdomen. The extensive- 
ness of the field of exploration thus opened through the rectum, 
and the accuracy of the results of palpation lead me to consider 
the examination with the half or whole hand as applicable to all 
cases of important affections of the pelvic or abdominal organs, 
when the modes of exploration hitherto usually employed do not 
give sufficient information. The inconvenience of putting the 
patient under chloroform is, in my opinion, completely out- 
weighed by the importance of the information obtained in this 
manner. The manual examination may be assisted by the simul- 
taneous palpation of the organs in question with the other hand 
through the abdominal walls (bi-manual examination) as is like- 
wise done in the ordinary explorations per rectum with one or 
two fingers." 

In his monograph on the " Manual Palpation of the Itectum" 
this author subsequently modified his views and qualified his state- 
ments concerning this mode of exploration. The general expe= 
rience now is, that too much has been claimed for it, and that it 
is only adapted to those rare and difficult cases in which every 
possible means of clearing up the diagnosis is justifiable. Theo- 
retically it is all that we could desire, but practically, as a single 
resort, and by itself, it is not to be depended upon. The opinion 
expressed by Emmet is quite to the point.* 

" I have succeeded in passing my hand into the rectum several 
times, and without the slightest bad result, as the sphincter en- 
tirely regained its power in a few days; but I succeeded in gain- 
ing no further information than, nor even as much as I could with 
one or two fingers alone, since, from the cramped position of the 
hand, there was no freedom of motion. To introduce the hand 
it is always necessary to administer an anaesthetic. If this is done 
I can, with two fingers, reach well up to the sigmoid flexure, and 
by conjoined manipulation make a still more thorough exploration 
of the pelvis. As the sigmoid flexure is so bound down, I cannot 
divest myself of the conviction that it is dangerous to attempt to 
pass beyond it." 

When we reach the subject of uterine and ovarian tumors, more 
especially in my clinic and at the operating table, I shall have 

* The Principles and Practice :f Gynaecology. By Thomas Addis Emmet, M.D., etc., 
etc. 18T9. p. 70. 



PHYSICAL DIAGNOSIS CONTINUED. 83 

more to say of the use and abuse of Simon's method of rectal 
exploration. 

The " Touch " as applied to the Bladder. — The definite propo- 
sition to pass the finger into the bladder for the purpose of apply- 
ing the " touch " to the body and fundus of the uterus anteriorly, 
was first made by Noeggerath in 1875.* The operation consists in 
the dilatation of the urethra, either slowly, by means of a suit- 
able instrument, a long sponge tent, or laminaria 
bougies, or rapidly, by a Moles worth's hollow 
rubber bougie, or by the direct and forcible introduction of the 
-finger. The patient should be placed under the influence of chlo- 
roform or ether, and, on account of the risk of haemorrhage, the 
dilatation should not be practised at or very near the menstrual 
period. The rectum should first be emptied, and the vagina 
cleansed with an injection of carbolic acid and water; and, in 
order to counteract the effect of the vaginal 

Precaution. , . „ ' . ... „ 

mucus on tne urine, as a cause of alkaline fer- 
mentation, the finger should be anointed with carbolized cosmoline, 
or a similar disinfectant. 

Since the course of the urethra is parallel to the posterior sur- 
face of the symphysis pubis, the patient should lie upon her back, 
with the limbs drawn up, as for lithotomy. The index finger of 

the left hand having been passed into the blad- 

The vesicovaginal and d ^^ f ^ . ^ ^^ j be . ^_ 

the rectovesical tuuch. " J 

duced into the vagina, or into the rectum, as the 
<?ase may require, and either form of conjoined manipulation be 
practised at will. This gives you an idea of what is known as the 
vesico-vaginal and the vesico-rectal touch. 

The kind of cases in which it is claimed that these methods of 

exploration are useful and practicable are those 

cases to which it is in wn ich, on account of the density or rigidity 

suited. 7 ° J 

of the abdominal and vaginal walls, the usual 
application of the " touch " has not been satisfactory. These cases 
include the recognition of small tumors within the pelvis ; a final 
test for inversion of the womb, and for a congenital absence or 
malformation of the womb; the early diagnosis of pregnancy; 
for protecting the bladder against injury while removing a por- 
tion of the supra-vaginal cervix, and to complete the diagnosis of 
heteroplastic tumors in the i^eck of the uterus. 

*The American Journal of Obstetrics, etc., Vol. VIII., p. 123= 



84 THE DISEASES OF WOMEN. 

The risks of this expedient are serious enough to more than 

counterbalance the good results that may be expected from it, and 

the consequence is that it is not often resorted to ; nor is it in 

very good repute with careful gynaecologists. 

Risks and sequela*. ° . . ° F 

lnese risks include the danger from haemorrhage, 
from paralysis of the sphincter, with a resulting incontinence of 
urine, and lacerations and inflammation of the neck of the bladder. 
The range of use for this method of exploration, when it is expe- 
dient, is very limited, for it would not be warrantable in the early 
diagnosis of pregnancy, nor in the matter of detecting a con- 
genital absence of the uterus, is it in any wise preferable to the 
conjoined touch afforded by the catheter in the bladder and the 
finger in the rectum. 

The " Touch" as Applied by the Uterine Sound. — You are 
doubtless well aware that this instrument, of which you will 
find several varieties upon the table, has been in use for cen- 
turies. By the ancients it was regarded as a 
curative means. They scarcely used it for any 
other purpose than to replace the uterus when it had become dis- 




Ftg.12. The Uterine Sound. 

located. But, in the hands of modern gynaecologists, it is regard- 
ed almost exclusively as an aid to diagnosis. In this manner it 
enables us to diagnosticate : 

(a.) Certain Diseases of the Uterine Cervix. — If we know what 

the proper dimensions and length of the neck of the womb are, or 

should be, by passing this instrument, we can 

^ In diseases of the cer- ^j^ if ^ case Jg Qne Qf hypertrophy? atr0 phy, 

or immobility of this part of the organ ; if it is 
imperforate; if there is cervicitis, or a polypus, or uterine dis- 
placement. Atresia, obliteration and flexures of the cervix, as 
well as a more or less permanent closure of the internal os uteri, 
in mechanical and spasmodic dysmenorrhoea, are also recognizable 
by means of the sound. 

(b.) In diseases affecting the cavity and body of the uterus. — The 



PHYSICAL DIAGNOSIS — CONTIlsUED. 85 

Tery ease of introduction of the sound through the internal os 

uteri, during the inter-menstrual period, sug- 

in diseases of the uterine p- e sts that all is not right within the cavity of 

cavity. o o «/ 

the womb. It is a sign of endometritis, or of 
the presence of some foreign growth, as, for example, either sub- 
mucous or interstitial fibroids, polypi, hydatids, cauliflower ex- 
crescence, or of cancerous degeneration. 

• (<?.) To measure the size of the uterus. — In health the unimpreg- 

nated womb measures about two and a half inches from the os to 

the fundus uteri. But this organ is so disten- 

For measurement. ... . , , , . 

sible, so given to development and to variations 
in its size and capacity from pathological, as well as from physio- 
logical causes, that we may sometimes learn much in a diagnostic 
way from its actual measurement. This, of course, is best accom- 
plished by means of the uterine sound. Passing the instrument 
in the direction of the axis of the organ, through its whole length, 
and taking care to indicate the extent to which it has entered the 
uterus, we obtain the longitudinal measurement of that organ. If 
it is lengthened to four, six, or more inches, and the woman is not 
pregnant, or has not very recently been delivered, the informa- 
tion thus obtained makes us confident that something is wrong. 
By this means, therefore, we may be able to 
diagnosticate a longitudinal hypertrophy of the 
womb, a very interesting case of which, I will take an early occa- 
sion to show you. By it, also, we may detect sub-involution and 
super-involution, as well as enlargements of the uterus due to the 
development of various kinds of tumors, as, for example, uterine 
fibroids, within its cavity. Thus, in the case of Mrs. H., you will 
remember, although she had a large ovarian cyst which was re- 
moved in presence of the class, the uterus measured six inches, 
and was found upon actual inspection to be very considerably 
enlarged. In order to be accurate in this kind of measurement, 
it is well sometimes to use the graduated sound. 

(6?.) To test the mobility of the Uterus. — In not a few cases the 
non-susceptibility of the uterus to motion is a diagnostic test of 
great value. We apply this test by introducing the sound, and 
then observing whether, when we move it laterally and carefully, 
the womb moves along with it. If it does, the organ is free, and 



86 THE DISEASES OF WOMEN. 

not bound down by adhesions or organic cliange ; but if it does not, 
some pathological change has been going on which has resulted 
in its becoming glued or adherent to the neighboring parts. 

This sign is present in cancer of the inferior segment of the 

womb, and in certain confirmed cases of pelvic cellulitis, and 

more frequently in pelvic peritonitis. We also 

In uterine carcinoma . 1 . 

meet with it, but more rarely, m old, chronic 
cases of retroversion and of retroflexion of the womb, in which 
the organ is anchored, so to speak, by strong adventitious bands 
attached to the rectum and the posterior pelvic tissues. 

This, as you know, is one of the means of differentiating 
between uterine and ovarian and other abdominal tumors. Plac- 
ing the left hand over the abdomen, and mov- 

In uterine tumors. . . . ■ 

mg the sound in utero with the other hand, as 
I have just indicated, if the motion of the womb is communicated 
to the tumor, or, in other words, if the womb and the tumor move 
simultaneously, in the same direction and to the same extent, we 
are assured that the tumor is uterine. But if the uterus can thus 
be moved independently of the tumor, there is no doubt of its 
being extra-uterine. 

(<?.) In the diagnosis of Uterine Displacements. — It will occur 
to you, without doubt, that any considerable disorder of place in 

the womb would necessarily include a deviation 

In deviations of uterus. . . 

oi its axis from the normal one. The direction 
of its long diameter, and therefore of its curve, would be changed. 
Now, in order to ascertain what direction the luxated organ has 
taken, and the extent of the displacement, more particularly in 
versions and flexions thereof, we must depend almost entirely 
upon the sound. If the womb is in situ, what might be termed 
the pelvic curve of the instrument (as we speak of the pelvic 
curve of the obstetric forceps), looks forward, toward the sym- 
physis pubis^ and the point thereof corresponds with the axis of 
the superior strait. But if the womb is bent forwards, or back- 
wards, or laterally, the curve or concavity of the instrument will 
be found towards the bladder, the rectum, or the right or the left 
iliac fossa, as the case may be. Sims' uterine probe, which is a 
modified or attenuated sound, is sometimes very useful in this, 
class of cases. 

In prolapsus the sound enters more readily, and its point takes 



PHYSICAL DIAGNOSIS — CONTINUED. 87 

the direction of the axis of the inferior strait or of the vagina, 
and looks toward the hollow of the sacrum, or toward the sacro- 
vertebral eminence. In procidentia, the os being at the lowest 
part of the tumor, the sound may be readily introduced. By this 
means we differentiate between procidentia and inversion of the 
womb ; for, in the latter, the os uteri can not be found before the 
organ is reposited, and therefore in inversion it is quite impossible 
to pass the sound until that operation is performed. 

Of late years, as I have already said, the ordinary sound is not 
often used as a means of replacing the uterus. In exceptional 
cases, however, it may still be used for this 
wo F mb thereposition ° fthe Purpose. Drs. Elliott, Sims, and others, have 
brought out such improvements upon the old 
instrument as render it much more safe and valuable as a means 
of fulfilling this indication. 

= ^J ' ' ^JtKjjjIj^ Fig. 13. Valleix's Uter- 
ine Sound. 



I nave known physicians to fail to learn anything from a resort 
to the sound because they did not have tact enough to discover, 
and no one had told them, that there were certain times and sea- 
sons in which this instrument could be used to more advantage 
than in others. As a rule, I think you will find that the sound 
can be more readily passed in the early than in 
the later part of the day. If you can be per- 
mitted to make the operation early, before the patient is up, or 
has been upon her feet in the morning, it may be much more 
easily and thoroughly accomplished than if you wait until toward 
evening or bedtime. 

Sometimes it is well to select a time which is a few hours, or 
perhaps a day in advance of the menstrual period. The prepara- 
tory dilatation having been effected in advance 
^advance of the month- f t ^ e fl ow ^ the internal os uteri is lazily agape, 
and less irritable than usual, and the sound 
is made to enter with but little delay, pain or trouble. 

You would not attempt to pass it when the patient is very 
much alarmed or excited, agitated and appre- 

When the patient is calm. . . 

hensive. .Neither would it be advisable in 
case of menstrual retention with softening of the cervix, lest the 



88 THE DISEASES OF WOMEN. 

woman might prove to be enceinte, and you might bring on a 
miscarriage. Nor would it do any good, but might possibly do 
harm, to introduce it too soon after menstruation, or directly after 
delivery. Its use is also contra-indicated in pelvic peritonitis, 
pelvic cellulitis, and pelvic hematocele, for in cases of this kind it 
would cause great pain and might work serious mischief. 

Unless the cervix uteri is closed by an atresia of its canal, which 
is comparatively rare, the chief difficulty in introducing the sound 
is met with at the internal os. This obstruction 
teSum C . uUy at the ° s m ~ is caused either by a change in the course of the 
utero-cervical canal at that point, or by an 
irritable condition of the muscular fibres (which form a sort of 
sphincter about the orifice) which causes them to contract spas- 
modically on the approach of the instrument. 

It is a very common error to suppose that the healthy uterus is 

nearly straight, when in fact it is not so. Cruveilhier, and other 

anatomists, have shown that, even in little girls, 

Uterine axis not straight. . 1 

its fundus is thrown forward, as in anteversion, 
toward the bladder. Opposite the junction of the neck with the 
body of the organ, there is a curve which is in the form of an 
obtuse angle, as is shown most clearly in this beautiful model, and 
in the diagrams on the black-board. 

Now, in order to enter the uterine cavity, the instrument must 

follow this curve at the internal os uteri, otherwise its point can 

not reach to the fundus. If the curve, or 

Variation in uterine curve. .- 

flexion forward, were uniform and unvarying, 
in different women, there would be little trouble on this account. 
But it is not so. For we find that, even in healthy persons, there 
is the greatest possible difference, not only in the shape, size and 
position of the womb, but also in the course and direction of its 
canal. This explains the fact to which I have before alluded, 
that, having learned the individual peculiarity of a patient in this 
respect by the passage of the sound, it will be less difficult to 
perform the operation upon her in the future. There are many 
exceptions, however, to this rule. 

It is because of the varying course and curve of the uterine 

canal in different subjects, and in health and 
pSbl SGunxlthatis disease, that it is best to use a flexible sound, 

which is capable of adapting itself to the exist- 
ing curvature, instead of a very stiff one, which would not yield, 



PHYSICAL DIAGNOSIS — CONTINUED. 89 

and which would require more of force to introduce it. For this 
reason, the copper sound, and in some instances the whalebone 
probe, is preferable to Simpson's old-fashioned sound. This 
copper sound will insinuate itself, whereas in a considerable pro- 
portion of cases, the old one can not be introduced without an 
unwarrantable degree of force. Where the uterine canal is bent 
acutely, forming an elbow, or the uterus is twisted upon itself 
spirally, we may sometimes pass a Sims' probe, such as I hold in 
my hand, and then withdraw it so carefully that it will retain its 
shape. The larger sound can then be bent into the same form, 
and afterwards passed more readily. 

Concerning the best position for the patient to assume, some- 
thing will depend upon the nature of the case which is to be 
examined. Usually, it is best for her to lie 

Position of the patient. i -i p • i -iii 

upon her lett side, on the bed or couch, to have 
the thighs flexed on the abdomen, and the legs on the thighs. 
This will enable you to find the cervix most readily, and to give 
the proper direction to the point of the instrument, when it has 
passed into the cervical canal. If she lies upon the back, and the 
uterus is not prolapsed, more especiallv if the vagina is long and 
your index finger is short, you will experience considerable diffi- 
culty in reaching the neck of the womb at all. And when you 
liave reached it, the finger will come against the anterior lip, and 
the organ will recede into the hollow of the sacrum, so that it 
may be next to impossible to pass the sound even through the 
external os uteri. 

There are exceptional cases in which the womb is displaced in 
an upward direction, in which, no matter what the position of the 

patient, it is very difficult to pass the sound. 

An exception. . 

In these cases, it is recommended to let the 

patient stand upright, with her back against the wall, while the 

operation is being performed. But ordinarily this is not requisite. 

If there is retroversion or retroflexion, the woman may be 

placed on the bed, couch or table, as for the introduction of Sims' 

speculum, on the left side, far over upon the 
j^ displacements back- abdomen, with the right thigh flexed and the 

left one straight. Or, if this is not sufficient, 
with the aid of gravity, to bring the fundus forwards, so that the 
sound may pass readily, she may take the knee-elbow or prone 



90 THE DISEASES OF WOMEN. 

position. In the latter case, before she 2;ets upon the knees, you 
had better secure the cervix for fear it may recede and pass beyond 
your reach. This indication may be met by means of the uterine 
tenaculum, an ordinary volsellum, or what answers equally well* 
and is less painful, by introducing the sound as far as may be 
before she turns over, then keeping it within the cervix while she 
is changing her position. 

In ante version and anteflexion you may take the precaution to 
recommend her to lie on the back for a number of hours before 
in displacements for- y ou P ass the sound. She should a] so be 
ward * instructed not to void her urine unless it is 

absolutely necessary, for about the same interval, in the hope that 
its accumulation in the bladder may help to restore the womb to 
its proper position. Indeed, you should not forget that the full- 
ness or emptiness of the bladder and the rectum may greatly 
influence the facility with which it is possible to pass the uterine 
sound. 

It is the habit of some physicians always to use the speculum 
as a means of facilitating the introduction of the sound. 
Since the invention of Sims' speculum especi- 
lum^ndsounT ° f specu " a lty> tn * s P rac tice has become quite popular. 
My own opinion is that, while in rare cases it 
may be necessary to use these instruments conjointly, in ordinary 
practice we can get on quite as well, or even better, without the 
speculum and the tenaculum. You can learn to pass the uterine 
sound without the help of vision quite as soon and as adroitly as 
you can learn to pass the female catheter by the sense of touch 
alone, and without any exposure of the patient's person. And I 
think you should try to do so. 

The chief things to be done in acquiring this species of tact are 

to place the patient in a proper position, to ascertain the direction 

of the uterine curve, to manipulate carefully 

Points to be observed. p 

rather than forcibly, to have the proper mstru- 
ment,and not to be in too great a hurry. I have already spoken 
of the proper time and posture to be chosen. In order to learn 
the course of the uterine canal, the " touch" must precede the 
attempt to pass the sound. By passing the finger carefully on 
every side of the cervix, as high up as possible, you can get the 
direction of the cervical axis, and recognize any marked flexion of the 



PHYSICAL DIAGNOSIS — CONTINUED. 91 

uterus, which is most apt to take place at a point opposite the 
internal os uteri, where the peritoneal coat is lacking in front. 
In case of the different versions the os and cervix must be located 
before the sound could be introduced. 

In ordinary cases, and with the tip of the right index finger at 
the external os, the sound can be passed along its palmar surface,, 
while being guided by the left hand, and made 
to enter the canal of the cervix. When it has 
passed an inch or so within that canal, the handle of the instru- 
ment should be depressed toward the posterior commissure of the 
vulva, and its curve turned toward the symphysis pubis. A little 
delicate manipulation and tact will now cause it to pass through the 
internal os uteri and into the uterine cavity. Sometimes, how- 
ever, it may be necessary to withdraw the sound and to change 
its shape somewhat. Or it may have failed to pass because its 
point was lodged in one of the lacunae which are so numerous in 
the cervical canal. 

If you use too much force it is possible for the instrument to 

pass not into the uterine, but into the abdominal cavity. This is 

especially liable to occur in case the sound slips 

fo2e nger fr ° m t0 ° much an( ^ P asses i nto the Douglas cul-de-sac ; and 
also where the tissues of the uterine cervix 

have been softened and somewhat disorganized as the result of 

chronic disease. Fatal peritonitis has sometimes resulted from 

this accident. 

If the patient is young and nervous, tell her precisely what it 

is that you propose to do ; that there will be no cutting, and but 
little pain ; that, in truth, this is only another 
means of extending the " touch" farther than 

the length of your finger will permit. Her attention should be 

diverted while the operation is going on. 

There is as much difference between two of these sounds which* 

to all appearance are precisely alike, as there is between two 
catheters. One will find its way like an intel- 

Choice of a sound. 

hgent agent, but the other almost invariably 
goes wrong. When you have selected a good one, let me counsel 
you to use it habitually and exclusively. 

Above all things do not be in haste. This is a delicate little 
operation upon the careful performance of which more may depend 



1)2 



THE DISEASES OF WOMEN 




Sims' elevator as a 
sound. 



than you perhaps imagine. At any rate you will be more likely 
to fail than to succeed if you are rash and pre- 
cipitate. It is better to take fifteen, twenty, 

thirty, or more minutes and do no harm, than to hurry the thing 

over without doing any good, or learning any- 
thing. If you fail altogether at one session, 

make another appointment with your patient 

and try again. You may be more successful 

next time. 

Case. — Some of you will remember a case 

in my clinic during the 

spring term, in which it 

was impossible to pass any 
form of uterine sound that we could find. 

Prof. , an expert gynaecologist, being 

present tried for a long time, and finally gave 
it up. One week later I resorted to an ex- 
pedient which I had twice tried before in sim- 
ilar cases, which was to use a Sims uterine re- 
positor as a sound, and succeeded in a very few 
moments. The case proved to be one of a 
fibrous growth in the supra- vaginal portion of 
the cervix anteriorly, and my theory was that 
only such a sound as could be bent at a very 
acute angle, and the elbow of which was firm, 
could possibly enter the womb. Here is the in- 
strument: 

Another use of this elevator as a sound is to 

pass it through the internal os-uteri, in order 
to fix the womb while the 
abdomen is being examined 

in case of fibroids and other abdominal tumors. 
A few years ago I fell into the habit, in my 

clinic, of using the sound in a particular man- 
ner in the diagnosis of uterine 
fibroids. It consisted in first 

passing the instrument, and afterwards, with 

the hand upon the abdomen, rolling the tumor 

and observing whether the sound moved con- 
sentaneously with it. This plan, which an- FlG - u - Sims ' Elevator. 

swered an excellent purpose at our clinicaltable, may serve you 

equally well when the same manipulation with the touch applied 

to the cervix, is not altogether satisfactory. 



The elevator in fibroids. 



The sound in fibroids. 




PHYSICAL DIAGNOSIS — CONTINUED. 93 

Another of my " wrinkles " is to use the sound instead of the 

tenaculum or the volsella, to bring the uterus towards the vulva 

for a more careful inspection and exploration. 

Jtonrt.rn.fb. tea- TMg ; g d(me by fag ^ g . % carefu j ly through the 

internal os-uteri to the fundus and allowing it 
to remain in situ for the space of five or ten minutes, when, if the 
uterus has no unnatural attachments, the organ will descend and 
come readily within our reach. As an operative expedient, how- 
ever, this mode of bringing the uterus downwards Aviil not answer 
our purpose. 

As a modification of the sound for the purpose of extending the 

touch to the uterine cavitv. in case of a verv 

The uterine probe. " ' . J 

narrow or tortuous canal ot the cervix, and for 
the delicate recognition of inequalities of the uterine mucous sur- 
face, as well as of intra-uterine growths, the probe is very usef ul. 
There are several varieties of these probes, of which the flexible 
silver one, known as Sims' probe is the best. 



tins! 



Fig. 15. Sims' Silver Probe. 



Thomas' hard rubber probe, and his elastic probe also, are some- 
times of excellent service. 



Fig. 16. rhomas' Hard Rubber Proba. 

4. Percussion. — In the application of percussion and ausculta- 
tion to the diagnosis of those uterine and ovarian tumors which 
are above the superior strait of the pelvis, it is 
inftumo S r i s t . i0n0fUter " vei T fortunate that they almost always come 
forward and lie against the abdominal walls. 
By so doing they push away the intestines and are directly acces- 
sible. This fact renders their removal, as well as their diagnosis 
possible, and it should always be borne in mind. 

Two objects may be gained by percussion when it is applied to 
the diagnosis of abdominal tumors : 

(1.) It enables us to map the outline of the tumor or tumors; 
and (2), by detecting fluctuation, to recognize the presence of a 
fluid when it exi& sin the tumors. 



94 



THE DISEASES OF WOMEN, 



In the healthy state the intestines which float within the abdo- 
men, and which are in contact with its parietes, 



The intestinal reso- 
nance . 



are so filled with g-as as to give rise to what is 



The uterine tumor in 
pregnancy. 



called the " intestinal resonance " on percussion. 
There is a condition, however, in which the area of this resonance 
may be diminished physiologically. When the gravid uterus rises 
above the superior strait, after the fourth month, its fundus 
inclines forward, and, in proportion as its size 'Increases with 
advancing pregnancy, the area ot dullness on 
percussion also increases. So that, in this case 
we have a uterine tumor which is not morbid, 
and the outline of which can be indicated by this mode of physical 
examination. 

In diseased states, when a tumor of any kind, whether it be 
solid, fluid, or composite, lies in contact with the parietes of the 
abdomen, similar conditions obtain, and we take 
advantage of this fact to indicate their topogra- 
phy. The area of dullness is in proportion with the extent of the 
tumor which lies directly against the internal surface of the 
abdominal walls, and which pushes the intestines away, either lat- 
erally, posteriorly, or upwards into the epigastric region. 



The area of dullness. 




In ascites. 



Fig. 17. Diagram of the ascitic outline. 

In ascites, when the patient is lying upon her back, and when 
the accumulation of the dropsical fluid is not 
very large, the dullness on percussion is at the 
sides of the abdomen and above the symphysis pubis; and the 
area of intestinal resonance is around the umbilicus. This condi' 
tion is clearly shown in the drawing: (Fig. 19.) 



PHYSICAL DIAGNOSIS CONTINUED. 



95 



If, however, the peritoneum is more fully distended, and the 
accumulation is very large, the characteristic resonance of ascites 
in the region of the umbilicus may be lacking altogether, and the 
whole extent of the abdomen be dull on percussion. 

In ovarian dropsy, no matter what the posture of the patient, 
if the tumor is large enough to extend beyond 
the umbilicus, with very few exceptions there 
will be dullness on percussion throughout its whole extent, and the 



In ovarian dropsy 





Fig. 18. Dullness in ovarian dropsy. 



Fig. 19. Dullness in ascites, etc. 



rounded outline of the tumor can be more easily distinguished. 
In this case the intestinal resonance will be found above, and at 
one or both sides of the cyst, as is shown in this diagram . 

It is very important for you to remember that it sometimes 
makes considerable difference whether percus- 

P a T tfenr StUrPOf ^ sion is a PP lied while the patient is standing, or 
when she is lying down. In ascites the same 
rule holds as in the case of hydrothorax; the line of dullness is 
concave when the patient is standing erect, and perpendicular, 
with the axis of the body when she is lying down. In ovarian 
-dropsy the outline of the tumor, and of the dullness also, is always 
convex. Here we have another illustration: (See Fig. 17.) 
Percussion is often useful in the detection of enlargements of 



96 THE DISEASES OF WOMEN. 

the uterus and its appendages, from other causes ; as, for example , 
in uterine fibroids of a considerable size, hydatids 

Percussion in uterine //• 1 1 ni\ l ^ i -ii- 

tumors, (lalsely so-called), cysts ot the broad ligament, 

extra- uterine pregnancy, in tumors formed by 
the effusion of serum, in pelvic peritonitis and pelvic cellulitis, and 
by the accumulation of blood in pelvic hsema^ocele. Its practi- 
cal application to these forms of uterine disease will be considered 
at the proper time. 

5. Auscultation. — Whether mediate or immediate, ausculta- 
tion is practised in the same general way as in the physical 

diagnosis of diseases of the chest. Its use in 

Use and range of . ° . 

gynaecology is, however, much more limited. 
A few years ago it was claimed that peculiar and distinctive vas- 
cular murmurs were always present in ovarian dropsy, and that 
the souffle which may be heard in uterine fibroids (especially at 
the month, when the texture is more loose and relaxed), had 
a certain diagnostic significance. But these theories have been 
abandoned, and the only real practical use of auscultation in gynae- 
cology in our day is limited to the detection and recognition of 
the foetal heart sounds in case of pregnancy. 

6. Tapping. — Paracentesis of the abdomen is less in vogue than 
formerly, because its abuse has often been productive of mischiev- 
ous results. When the contained fluid is thin enough to run 
through an aspirator-trocar, it may sometimes be well to draw off 
a sample for examination; but it should not be done indiscrimi- 
nately. As occasion offers in my clinics, I shall teach you how to 
properly use this means of diagnosis. ( See Lecture LYIII. ) 

7. The Exploratory Incision.— This is so valuable and impor- 
tant an aid to diagnosis that it is the final appeal in doubtful cases 
of abdominal disease of almost every description. During the 
course of the winter we shall probably have occasion to resort to 
it. (See Lecture LYIII). 



Part Second, 



THE DISEASES OF PUBERTY. 



LECTURE VI. 



CHLOKOSIS. 



CTilorosis. Case.— Digestive, cerebral and cardiac symptoms, scrofulous do., blood changes 
in,— the nervous symptoms; the pulse, the appetite, menstrual derangements, the 
skin ; etiology of ; diagnosis of, from jaundice and anasmia ; prognosis ; treatment, for 
the general and emotional causes, the cachexia, iron in, the citrate of iron and strych- 
nia in. Case, special indications for remedies— the diet, exercise and travel. 

Case. — Miss , aged 18, complains of a complete loss of appe- 
tite, and of headache. She is listless, and snilers greatly from 
palpitation of the heart, especially after exercise. At times, she 
has a dull, dragging pain in the cardiac region. The anaemic 
murmur (bruit dediable) is easily recognized. Until about a year 
ago she felt very well, but since that time these symptoms have 
been steadily increasing in severity, The skin is pale, of a green- 
ish-yellow tint, and almost transparent. Her lips, tongue, and 
alee nasi are almost colorless. The eyelids and features are slight- 
ly oedematous, particularly after sleeping. The teeth are decayed, 
the fingernails brittle. She has never menstruated, and says that 
her mother and her elder sister were more than 19 years old when 
their menstrual function was first established. 

In rare instances chlorosis is a congenital affection. A large 

proportion of cases occur in the young and unmarried. Absence 

or suppression of the menses is so frequent and 

^Chlorosis and amenor- almost invariable an accompaniment ■ of chloro- 

sis, that some authorities have regarded it as 
identical in nature with amenorrhcea. Others are not decided as 
to which is cause and which effect — whether the chlorosis is the 
cause or the consequence of the menstrual derangement. 

We remark in chlorosis a decided impairment of the vegetative 

functions. There is always more or less of headache, anorexia, 

gastric derangement, dyspnoea, fluttering, pal- 

lgestive symptoms. p^ a ^ on? timidity, general malaise, constipation, 
and hypochondria. In some cases "these symptoms persist for 
years without proper recognition and relief. They are exceedingly 
ly common among young, delicate girls, especially among those who 
work in shops and factories, and who follow sedentary pursuits, as 

7 97 



98 THE DISEASES OF WOMEN. 

seamstresses and school-teachers. Their persistence and the 
accompanying ill health frequently lead physicians to decide that 
such patients are suffering from inflammation of the brain or its 
membranes, ulceration of the stomach, phthisis pulmonalis, organic 
disease of the heart, of the liver, or of some*6ther organ. 

The headache is very prone to take on the form of hemicrania, 

and is not unfrequently mistaken for neuralgia. Sometimes it is 

regularly periodical. It is always paroxysmal, 

Cerebral symptoms. ° . , . , 

and is greatly aggravated by emotional causes, 
over-anxiety, and too much of mental labor or worry. In rare 
cases it is so severe in degree as to produce delirium, spasms, and 
even mania. And thus it happens that the patient may suffer a 
temporary loss of memory, or she may decline into a state of men- 
tal torpor, and general insensibility. Chorea, hysteria, partial 
paralysis, and epilepsy, are among the possible concomitants and 
sequelae of this headache in chlorotic subjects. 

While they are really the least serious, the heart symptoms are 
the most alarming to the patient and her friends. Chlorotic pal- 
pitation, as it is termed, is due to a functional 

Cardiac symptoms. ~ _ 

change m the rhythm 01 the heart s action ; 
this change is of nervous origin, and has no necessary connection 
with organic disease of the heart. It may continue for years 
without inducing any structural changes, or the prolonged func- 
tional disorder ma} r insidiously injure the heart's texture. 

There is a strange relation or sympathy between the generative 

system of the female and the heart. One woman 1ms menstrual 

retention from dysmenorrhcea, and all her suf- 

Sympathy between gener- f er i ng r S are referred to the cardiac region. 

ative organs and the heart. o o 

Another has menorrhagia, and she complains 
only of similar symptoms. A third, who has chronic ulceration 
of the os uteri, tells the same story. In a fourth, the sole patho- 
logical result of an excess of sexual indulgence is disclosed in the 
same identical symptoms. The same may be true of amenor- 
rhea, prolapsus, ovaritis, and chlorosis. By physical exploration 
we can detect no difference in the incidental conditions of the 
heart. The whole precordial trouble is symptomatic, nor will 
the objective cardiac symptoms enable us to differentiate between 
them. 

In chlorosis the pulse is usually, but not in every case, slower 



CHLOROSIS. 99 

and weaker than natural. It may not exceed fifty or fifty-five 
beats in the minute, and is sometimes as low as 
forty-five or forty-eight. Now and then, how- 
ever, you will encounter a case in which it is considerably quick- 
ened. As a rule, the more marked the anaemia the more frequent 
the pulse, providing, of course, that the impoverished condition 
of the blood is not the result of sudden and excessive haemorrhage. 
In chlorosis, as in hysteria, the pulse has this characteristic, that 
whatever its usual rate of frequency, no matter what the condi- 
tion of the patient, or the circumstances in which she may be 
placed, that rate is but little, if at all, changed thereb}\ 

The anaemic murmur, (bruit de dialled) which, in most cases of 
chlorosis, may be heard over the precordial region, but more dis- 
tinctly along the course of the great vessels, as 

The anaemic murmur. . . . 

the carotid and iemoral arteries, is a curious and 
suggestive symptom. Some authorities believe it to be caused by 
an impoverished condition of the blood, in which there is a defi- 
ciency in the proportion of red corpuscles. Others ascribe it to a 
diminution in the volume of the blood contained in the vessels. 
It occurs in anaemia as well as in chlorosis. 

There is not unfrequently a total loss of appetite. The patient 
may subsist for months upon an incredibly small quantity of food. 

In other cases the most unheard-of caprices are 

The appetite. . _, - 

likely to be indulged. She craves such outre 
articles as chalk, plaster, bits of clay, of coal, or of slate-pencil, 
cinders, sand, magnesia, grains of coffee, and vinegar. A fre- 
quent peculiarity of the appetite is a total disrelish for, and dislike 
of, every variety of animal food. One of my chlorotic patients 
had not tasted a mouthful of any kind of meat for more than ten 
years. In some the appetite is fitful. They will fast for a long 
time, and then eat excessively. Generally, they do not anticipate 
or enjoy their meals, but " go through the motion " of eating at 
stated periods, simply because it is expected of them in the fam- 
ily and in society. 

In consequence of this impairment of the digestive functions, 
a train of symptoms is sure to follow. The bowels become in- 

veterately constipated, or there may be alterna- 

Incidental symptoms. . 

tions ot constipation and diarrhoea. The breath 
is sometimes disagreeable, or even foetid. In a few cases observed 



100 THE DISEASES OF WOMEN. 

by Marshal Hall, it had the odor of new milk. In very rare and 
extreme cases hsematemesis or malaena may ensue. Sometimes 
there is obstinate and persistent ulceration of the stomach, with 
intractable vomiting of ingesta. The cellular and muscular tis- 
sues become flabby. There is general and progressive emaciation. 
She becomes bed-ridden, and is believed to have passed into a 
hopeless decline. A species of dropsy, either general or locals 
may supervene. Some patients with chlorosis suffer great torture 
from gastralgia. In others there may be successive attacks of 
gastro-enteritis. Organic lesions of the liver and spleen are fre- 
quent concomitants of chlorosis, especially in the west and south- 
west, and in all malarial regions. 

It is unusual for this disease to exist without more or less mens- 
trual derangement. The most ordinary complication of this kind 
is with amenorrhcea. The chlorosis may set in 
in^roSs 1 irregularities before the menses have appeared, at puberty, 
and they may fail altogether. Or there may be 
an incidental and prolonged arrest of the flow in those who have 
menstruated before. In either case, the menses do not appear for 
months, and perhaps for years. The suppression-may date from 
the commencement of the chlorosis, but most frequently it follows 
in the train of other symptoms. The chlorosis is very apt to come 
on stealthily and insidiously, so much so that neither the patient 
nor her family remark anything wrong with her health until the 
disease is pretty well developed. She may have complained for a 
considerable period of symptoms of which I have spoken, and in 
addition have noticed that her catamenial discharges were less free 
than natural, but it is not, perhaps, until the flow has ceased alto- 
gether that any alarm is excited, or counsel desired in her case. 
It has frequently happened that the co-existence of amenorrhcea 
and gastric derangement has given rise to suspicions of pregnancy ; 
while in other cases, the arrest of the menses with troublesome 
chest symptoms has aroused suspicions of incipient tuberculosis. 
Although she is eighteen years of age, this woman has never 
menstruated. But in her case there is a family or hereditary idio- 
syncrasy which may explain this fact. Her 

Hereditary amenorrhcea." 

mother and sister were nineteen years old be- 
fore the menses appeared. We cannot, therefore, charge the non- 
appearance of the flow to the chlorosis, or vice versa. From which 



CHLOROSIS. 101 

3^011 will infer that although they may and do frequently co-exist, 
these disorders have no necessary relation with each other. 

You will sometimes meet with chlorosis in a patient who is 
subject to dysmenorrhea. In such cases, the incidental hysteri- 
cal s}^mptoms are more pronounced and per- 
^cworosisanddysmenor- s i s tent. They are very troublesome and diffi- 
cult of cure. The menstrual flow often be- 
comes so scanty as to increase the difficulty by its retention, and 
we may thus have a case of painful menstruation resolving itself 
more and more into one of entire suppression. Or the dysmenor- 
rhea may develop into menorrhagia, which will further compli- 
cate the chlorosis. 

Chlorosis is also incident to those states in which menstruation 
is physiologically suspended. It may occur 

Chlorosis in pregnancy, etc. . . -i -i -i i -i -i • i. 

during pregnancy, m child-bed, during lacta- 
tion, or after the grand climacteric. 

The peculiar discoloration of the skin, which is very marked 

in this case, is pathognomonic. In mild and recent attacks it is 

of a pale greenish tint. Hence the popular 

Discoloration of the skin. . 

name, " green sickness. lhe lips, alse nasi, 
the gums, and the tongue, lose their vermillion hue. The skin 
is sometimes of a yellowish cast. (Sauvage called chlorosis 
" white jaundice.") In later stages of the disease, and in very 
bad cases, the discoloration is more marked. The skin becomes 
of a waxy, dull leaden, slate-color, sallow, or dirty-white hue, 
and there are dark lines beneath the eyes, and at the angles of 
the mouth. The white of the eye has a peculiar pearly, trans- 
lucent appearance. The face becomes tumid, and the eyelids, 
especially the upper one, puffy and ceclematous. The general 
surface of the body appears dry, bloodless and opaque. The hands 
are shriveled, the nails split, brittle and broken. 

Patients with this disease are averse to exercise, and to society. 
They become listless, and sometimes pass into a state of pseudo- 
narcotism ; or they are low-spirited, and look 

The mental state. -i -i p • 

upon lite and the future with the most gloomy 
forebodings. They are disposed to melancholy. They lose 
interest in their studies, permit their accomplishments to grow 
rusty from disuse, and, in brief, are really wretched. 

Etiology. — The causes of chlorosis are predisposing and excit- 



102 THE DISEASES OF WOMEN. 

ing. Among the former, the most prominent is the lymphatic 
temperament. It is extremely rare to meet 

Chlorosis and scrofulosis. . , . , - , , ~ , . „,, . 

with it m any other class 01 subjects. I his 
predisposition is strengthened by a tendency to scrofula. In 
these persons the blood-making function is liable to such dis- 
order as results in a deterioration of the quality of that fluid. 
Hence the relative diminution of the red corpuscles, and the pro- 
portionate increase in the watery part of the blood, which are 
almost always present in chlorosis. This predisposition is fostered 
by whatever hygienic influences may tend to lower the standard 
of health, and to vitiate the process of sanguification. These 
causes are usually classed as exciting ; but they are only remotely 
so. They include an exclusive diet of indigestible, inappropriate 
or unwholesome food, confinement in damp, shady, illy-ventilated 
apartments, deficient exercise and clothing, unrequited affection, 
nostalgia, ennui, chagrin, jealousy, fright, sexual excitement, and 
uterine and ovarian disorders. 

Most authors will tell you that chlorosis arises from " a disease 
of the blood," a phrase which is utterly destitute of meaning. 

It is true that in many cases the proportion of 
s . Biood-changes in chioro- t ^ G red globules Is deficient i but unless it be 

traceable to a loss of blood by haemorrhage, 
that is a symptom merely. In anaemia from haemorrhage of any 
kind, the poverty of the blood is accidental, and due to an actual 
loss or withdrawal of the colored corpuscles. In chlorosis, the 
change in the composition of the blood has been gradual, is the 
woik of disease that has implicated and impaired the process by 
which the blood itself is made. In the one case it is a chance 
effect ; in the other a natural and necessary consequence of 
diseased action. 

I have already explained the physiology of hyematogenesis. 
You are familiar with the function of the lymphatic glands and 

their duties in this relation. Without their 

Haematogenesis. 

aid, the blood could not be manufactured. It 
is a peculiar predisposition to disease in them which constitutes 
the chlorotic diathesis. But these glands cannot operate inde- 
pendently of the nervous system, any more than the liver or the 
pancreas. And so we must go back of them for the prime cause 
of the disorder. 



CHLOROSIS. 103 

It is " begging the question"' to refer the essential pathology of 
chlorosis to an impoverished condition of the blood. That fluid 

may contain seven-tenths, or even nine-tenths 
roS?nd£nSf ia in chl °~ seru m, as found in Jolly's analysis of the blood 

of chlorotic subjects, but it will not suffice to 
declare that all the symptoms in this disease are due to, and 
depend upon, this condition alone. Nor does the relative loss of 
the red globules represent the disease. The special pathology 
and etiology of chlorosis are not to be found in the hydremia, 
spansemia, or the chloro-ansemia, which in most cases are attend- 
ant upon it. For occasional well-marked cases of this disease are 
certainly met with, in which there is no manifest change in the 
composition of the blood. 

Numerous reasons have been adduced for a belief in the ner- 
vous origin of chlorosis. Thus Eisenmann* assigns the following : 

"(a) In certain cases Becquerel and Roclier 

The nervous theory. _ •i-i-it 

tailed to detect any changes in the blood, (o) 
Chlorosis is much more frequent in females than in males, and it 
is a well-known fact that the nervous system predominates in the 
former, (c) The incipient symptoms of chlorosis, those which 
anticipate any change in the blood are nervous, and those nervous 
symptoms continue through the whole course of the disease. (cT) 
Chlorosis yields to those remedies which are known to act favor- 
ably in affections of the spinal cord, as morphia, strychnia." etc. 

To these we may add that many attacks occur in those who are 
predisposed to chlorosis, in consequence of fright, the exercise of 
strong mental and moral emotions, sexual excitement, masturba- 
tion, and the nervous tension incident to city life and society 
among the better classes. Dr. Clotar Miiller bases his assump- 
tion of the nervous origin of chlorosis on (a) " the great influence 
which mental emotions and certain depressions of the nervous 
system exert upon the origin and development of chlorosis ; and 
(5) the powerful curative influence of remedies acting directly 
upon the nervous system, and manifesting an influence corres- 
ponding homceopathically to the depression and general prostra- 
tion of vital power peculiar to this disease."! 

The same author says : " If I may venture to draw a conclusion 
from my own observations, I should assume as most probable that 



* Bulletin de Therapeutic, Sept. 30, 1S59. 

f Vide North Am. Horn. Quarterly, Vol. VII, 



p. 158. 



104 THE DISEASES OF WOMEN. 

chlorosis is originally an affection of the spinal and ganglionic 
systems of nerves, having a character of weakness and exhaustion 
combined with erethism and excessive excitability." Becquerel 
and Roclier confirm this view : " For us, as for some other authors, 
chlorosis is a disease which has its beginning and its seat, its 
point of departure primarily, in the nervous system, giving rise 
consecutively to disorders of digestion, of menstruation, and of 
the circulation. If this definition is correct, the change in the 
blood in chlorosis is not a constant and capital fact, but a second- 
ary, incidental phenomenon, which is not absolutely indispensable 
to the disease."* 

Gabalda says emphatically, " We regard this disease as a per- 
fectly distinct neurosis." M. Jolly and Dr. Tilt insist that 
chlorosis is a neuralgic affection of the ganglionic system. Dr. 
H. Jones, that " in many cases, occurring among the poorer classes 
in London, the action of malarious influences upon the ganglionic 
system is the first link in the chain of causation." 

Upon this theory, which is so well supported by facts and by 
medical authority, we are able to explain the insidious and pecul- 
iar character of this complaint Its seat is in the nervous system. 
Back of all the symptoms disclosed by the solids and fluids, the 
cause is at work to undermine the general health. And thus it 
happens that in confirmed chlorosis " there appears to be not a 
system, an organ, a texture, or even a fluid, in the animal economy, 
which does not suffer." 

I have already said that the menstrual disorders incident to 
chlorosis are generally considered as the cause, and not the con- 
sequence thereof. The argument against this 
enor h rhi a 1S etr ecedes am " hypothesis is short and simple. In a majority 
of cases the manifest signs of chlorosis appear 
before there is any derangement of the monthly periods. In some 
instances the menstrual function escapes all implication, and the 
patient has chlorosis without any catamenial irregularity whatever. 
Now, if the non-appearance of the flow, or its suppression, or 
even its excess, were the cause of this disease, 

S ymp?omadc! :ompIications one or tne otner should always precede the 

pallor of the skin, and the nervous, circulatory, 

and digestive symptoms of chlorosis ; this affection could never 

* Traite de Chemie Pathologique appliquee a la Medicine Pratique. 1S64 ; p. 155. 



CHLOROSIS. 105 

exist in one who menstruates regularly ; nor could it ever occur, 
as it really does, in the male subject. We therefore conclude 
that the menstrual complications incident to chlorosis are symp- 
tomatic, and not idiopathic. The real disease is the chlorosis, 
and not the amenorrhoea, the dysmenorrhoea, or the menorrhagia. 
It is said that in the West Indies many male negroes formerly 
sickened and died of a disease which, in all of its principle 
features, was identical with chlorosis. 

With characteristic originality, Prof. Meigs styled chlorosis an 
*' endangial disorder." He referred all the symptoms, but more 
especially the changes in the composition of the blood, to a path- 
ological state of the endangium, or lining membrane of the circu- 
latory vessels. 

Dr. Von Maack* holds that, in chlorosis, it is impossible for the 
iron of the food to be changed into haematin and fixed. And this 
because the saccharine function of the liver is either disordered 
or arrested. But this must suffice for the etiology of chlorosis. 

Diagnosis. — You will not be very likely to confound chlorosis 
with jaundice. The pearly look of the white 

Chlorosis and jaundice. . 

oi the eye in the iormer disease, and its yellow 
cast in the latter, will enable you to differentiate between them. 

I have drawn the following table, which may help you to diag- 
nosticate chlorosis from anaemia : 

CHLOROSIS. ANEMIA. 

1. Is an idiopathic affection. i. Is an accident, or sequel of other dis- 

eases. 

2. Is not caused by the loss of blood, or 2. Is frequently caused by haemorrhage, 
other debilitating discharges. suppuration, leucorrhcea, diarrhoea, 

colliquative sweats, etc. 

3. May result suddenly from mental 3. Never does, 
causes alone. 

4. The mental and nervous symptoms are 4. Not so in anaemia, 
especially prominent. 

5. The nervous symptoms initiate the 5. The opposite occurs in anaemia, 
attack. 

6. Fugitive neuralgic pains in the head, 6. These pains are lacking, 
the spine, the stomach, the chest, and 

especially in the side, are almost inva- 
riably present. 

7. May be accompanied or followed by 7. These complications and sequelae are 
hysterical spasms, chorea, paralysis, or not incident to this affection, 
epilepsy. 

* L'Union Medicale, February, 1859. 



106 THE DISEASES OF WOMEN. 

CHLOROSIS. ANAEMIA. 

8. The skin is of a greenish, or greenish- 8. The skin is blanched, pallid, puffy, and 
yellow tint. doughy. 

9. Hemorrhages are not very frequent. 9. Haemorrhages are very frequent. 

10. Is very rare in male subjects. 10. Affects the s exes indiscriminately. 

11. Rarely happens in those who are under 11. May occur at any age. 
twelve or over thirty years old. 

12. Is limited to women of lymphatic tern- 13. May happen to women or men of any 
perament. temperament. 

13. Is very liable to be accompanied by sup- 13. Is more likely to be accompanied by 
pression or retention of the menses. too frequent and copious menstrua- 
tion. 

14. May exist and run its course without 14. Is always characterized by an impov- 
any perceptible change in the composi- erishment of the blood. 

tion of the blood. 

15. The degree of change in the blood bears 15. The impoverishment of the blood is in 
no necessary relation to the severity of direct ratio with the degree of func- 
the disease. tional disorder. 

16. Is most common among the better 16. Is most common among the poorer 
classes of society. classes. 

Although these symptoms are sufficiently distinctive, it some- 
times happens that a diagonsis between these affections is extremely 
difficult, if not altogether impossible. There are, doubtless 
exceptional cases, in which they co-exist in the same patient. 

[Two Cases, Nos. 6366 and 7541, were shown to the class, sitting' 
together, in order that their symptoms and treatment might be 
compared. The first of these had anaemia with vicarious menstru- 
ation ; and the second was a decided case of chlorosis. These cases 
were shown in the same way for some weeks, until they were 
discharged cured.] 

Prognosis. — In the milder forms, and under proper manage- 
ment, chlorosis, is curable. The chief danger is from incidental 
organic diseases, the most serious of which are 

tafdrsease fr ° miaCiden " cardiac aild pulmonary affections, myelitis, 
tuberculosis, dropsy, paralysis, epilepsy, and 
repeated haemorrhages. The disease is of a lingering, tedious 
nature, and patients get well or worse very slowly. But now and 
then one who has been ill with this disease for a lono- time dies 
suddenly without any premonition. For this reason, your prog- 
nosis should be guarded. 

It is a favorable sign if, under treatment, the appetite and spirits 
improve, and also if the menstrual irregularity is corrected with- 
out forcible measures. Kelapses are frequent. 

Treatment. — After this analysis of the disease in question, you 
are prepared to appreciate the difficulties in the way of its most 
appropriate and successful treatment. Its Protean phases and 
multiform complications sometimes embarrass the practitioner 



CIILOROMS. 107 

exceedingly. The rule, however, holds, that the more carefully 
the remedy is chosen, providing other very necessary conditions 
are complied with, the more certain and satisfactory is the result. 
In general, you should give especial prominence to remedies 
which are suited to derangements of the nervous functions, or of 

the circulation, or of digestion, or of menstrua- 
s tSs medies for seneral tion - These are cardinal points in the special 

therapeutics of chlorosis. In most cases, the 
characteristic indications are discoverable in them. In one per- 
son the nervous symptoms may predominate ; in another, the 
digestive , in a third, the sexual, and so on. Or, if they are min- 
gled, try to learn the order of their sequence, their cause or 
causes, and what constitutional or accidental agency serves to 
perpetuate the mischief. 

You may often find the proper remedy by selecting one that is 
appropriate to the mental or emotional condition which induced 

the attack. Our works on materia medica teach 
Treatment for emotional y 0U wna t these remedies are. Most prominent 

cause. J J- 

among them is ignatia. After this, there are 
belladonna, hyoscyamus, coffea, opium, aconite, and some others. 
In selecting from this, and a much larger catalogue, the indica- 
tions are very similar to those which call for certain remedies in 
hysteria. 

Calcarea carbonica, sepia, sulphur, natrum muriaticum, graph- 
ites, ferrum, phosphorus, plumbum, and similar remedies, are 
often appropriate for the chlorotic cachexia, 
Remedies for the chio- anc [ j n c i iron i c cases may sometimes be given 

rotic cachexia. J o 

temporarily with good effect, in lieu of other 
medicines. The first two are especially useful in the menstrual 
irregularities incident to chlorosis. The same is true of cyclamen 
and pulsatilla. Other remedies sometimes employed are kali carb., 
arsenicum, lycopoclium, conium, mix vomica, china, chamomilla, 
helonine, and senecin. Indeed, as in hysteria, almost any remedy 
in the wdiole range of the materia medica may be called for. It 
would be a work of supererogation, as inappropriate as a pater- 
noster, for me to detail all the symptoms which might indicate 
them in this connection.* 

Upon the theory that chlorosis and anaemia are identical, and 

* For particulars see N. American Hom. Quarterly, Vol. VII, p. 152, et scq. 



108 THE DISEASES OF WOMEN. 

that both affections are due to a deficiency of iron in the blood, 
iron is regarded by many physicians as a spe- 

Iron in chlorosis. . n , , . T . ■ , . ,.. 

cmc in chlorosis. It is almost as universally 
given in this disease as quinine in intermittent fever, or mercury 
in syphilis. But, for the best of reasons, it frequently fails to 
cure. In order to be useful, it should be prescribed upon patho- 
genetic indications, and in such form and quantity as to be avail- 
able. When there are only about thirty grains of iron in the 
whole mass of blood contained in the body, it surely is irrational 
to attempt to supply any deficiency thereof by thrusting large 
quantities of the crude metal, or any of its salts, into the stomach. 
Iron is not appropriate to those cases of chlorosis which are of 
nervous origin, or in which, from the onset of the disease, the 
nervous symptoms have been especially prominent. In anaemia 
proper it is more generally useful. 

In many cases of chlorosis there is, however a preparation of 
iron in which I have great confidence. This is the citrate of iron 

and strychnia, a salt which came into use some 
str^cw. ° f iron and years ago. I give it empirically in the third 

decimal trituration. In my experience nothing 
is so well adapted to control the whole train of symptoms in most 
cases, although it is by no means an invariable specific. It seems 
to combine the good qualities of iron with those which belong to 
the strychnia group. It will accomplish more than ferrum metal- 
licum, ignatia, nux, or strychnia, when given separately. I could 
detail several cases of this disease cured with this remedy alone. 
In this compound form it certainly merits 'a proving. 

Case. — A young girl, eighteen years old, has been ill four 
months. Although not obliged to keep her bed, she has to lie 
down many times during the day, because of severe pains in her 
stomach. Those pains are always in the same place, and are better 
after sleeping, and sometimes entirely disappear. Accompanying 
these pains there is sick headache and faintness, and a pain about 
the heart. There is difficulty in breathing, and she is obliged to 
sleep with her head high. She has a cough both clay and night, 
Avith but little expectoration. She is not rheumatic, but has had 
a white swelling on her right knee since she was two years old. 
Menstruation has been generally regular and normal since its 
establishment three years ago, sometimes a little too free, but more 
frequently scanty, and usually accompanied by severe pain. The 
complexion is very pale, and there are very dark circles under the 



CHLOROSIS. 109 

eyes. The tongue is pale, and the appetite capricious. Citrate of 
iron and strychnia 3, four times a day. 

Nov. 13. She has had no pain in her stomach since she ivas 
here, but the palpitation and the headache still continue. China 
3, in the morning and at noon, and citrate of iron at night. 

Nov. 20. She is very much better, the pain in the stomach has 
all gone, the headache is much better, there is more color to the 
tongue, she coughs less, but is still quite weak. Citrate of iron 
and strychnia four times a day, and spigelia 3, at night. 

Nov. 27. The patient is very much improved, with the excep- 
tion of the palpitation of the heart, which is aggravated by slight 
exercise. Spigelia 3 four times a clay. 

Dec. 3. She has not been so well this week. The menses came, 
continued three days, with no unusual symptoms. There has been 
no return of the stomach difficulty. The palpitation of the heart 
still continues. She has globus hystericus, which is -worse at 
night. The eyes are very sensitive to light, and she has consider- 
able vertigo and headache. There is no exhausting discharge. 
Belladonna 3, four times a day. 

Dec. 11. The palpitation is no better. She can sleep in the 
daytime but cannot at night. Her appetite is very poor; she is 
greatly exhausted after the least exercise, and has fainted twice 
after the attempt. Globus hystericus is better. Ignatia 3, four 
times a day. 

Jan. 8. She feels much better; has more color in her face. 
The palpitation is less; there has been no return of the gastric 
troubles or headache, but she is very weak, and fainted twice after 
a slight exertion. Spigelia 3, four times a day. 

Jan. 15. The patient is greatly improved. All the symptoms 
are better. Continue spigelia 200. 

Jan. 22. She is still improving. The palpitation and weak- 
ness, with fainting spells, have nearly disappeared. Same remedy. 

Jan. 29. " Feels splendid." She can walk, or go up stairs with- 
out the cardiac difficulty ; sleeps better at night. Continue spigelia 
200, four times a day. 

Feb. 5. Still improving. Same remedy. 

Feb. 26. She is very much better. All the symptoms are 
relieved. Continue spigelia 200. 

The patient reported again in March, and the remedy was 
changed to ferrum metallicum 3, three times a day. In April she 
came again to the clinic to assure us, by her general appearance, 
that the treatment which she had received had restored her to 
health. 

Phosphorus is useful in chronic cases of a 

Phosphorus and cai- tuberculous habit> When caused by srief or 

carea phos. J *"> 

worry, or blighted love, or the loss of "fluids, 
calcarea phos. will often answer, especially if puberty is delayed. 



110 THE DISEASES OF WOMEN. 

Kali carb. is adapted to cases with serious disorders of the 
digestive system, with thirst, a craving" for 

Kali carb. e J ° 

sugar, pumness over the eyes, constipation, and 
prolonged menstruation. 

Ignatia in nervous, hysterical girls and women, 
and when caused or aggravated by disappointed 
affection. 

Prof. Hoyne will tell you that calcarea carb. is " a very impor- 
tant remedy in bad cases, with perversions of 
taste; aversion to meat; longing for sour and 
indigestible substances; offensive breath; disposition to colds 
and diarrhoea; swelling and hardness of the abdomen; palpita- 
tion of the heart; great dyspnoea; great weakness of the spine; 
leucorrhoea, and coldness of the hands and feet." 

Dr. Holcombe calls attention to the phosphate of iron, in the 

first centesimal trituration, as especially adapted to chlorotic 

cases of lymphatic temperament and scrofulous 

Phosphate of iron. ,, ,. TT T 

constitution. He says: 1 was once treating a 
little child of the scrofulous diathesis, for ulceration of the cornea, 
conjunctivitis, and a vesicular eruption around the^eye. Sulphur, 
hepar sulphuris, calcarea and other polychrests had been tried in 
vain, when I suspended the special treatment to check a very 
profuse urination at night. I selected the phosphate of iron, 
although the acetate is generally better in such a case. To my 
great surprise the eye symptoms disappeared in a few days. The 
disease returned some months after, and was promptly cured by 
the same prescription. Since that time I have used it success- 
fully in many cachexias with degeneration of tissue." In excep- 
tional cases the arseniate of iron answers very well. 

Sepia is adapted to chlorosis with the following symptoms ; 
Palpitation of the heart, sudden flushings 
bearing down pains in the abdomen with pro- 
lapsus uteri and a yellowish leucorrhoea, and a premature and 
scanty menstruation, with a puffy, pale or yellow face. 

There is an acquired form of chlorosis which is the sequel to 
diphtheria. Dr. Gr. A. Macomber observed, that for this species 
of blood-degeneration, helonias was the best 
remedy. And, taking advantage of this clin- 
ical hint, we have found it of great service in chlorotic conditions 



CHLOROSIS. Ill 

following' an attack of diphtheria. It may be given alone, or in 
alternation with china or ferrum in one of its forms. 

For an interesting- paper on chlorosis arising from mental shock, 
I refer you to Dr. Hammond's recent report of several cases of this 
kind cured with arsenic and strychnia.* 

Much harm is sometimes done by attempting to force the men- 
strual flow. You should be careful to avoid this, remembering 

that the menses will appear as soon as the gen- 
menses, eral health warrants and favors it. Relieve other 

and more urgent symptoms, restore the physio- 
logical equilibrium , and this function will probably resume its accus- 
tomed order. There is good reason for believing that the non-ap- 
pearance of the menses in many cases of chlorosis is a conservative 
precaution, designed by nature to economize the patient's 
strength. 

An exception to the rule just specified is found in those cases 
of spasmodic dysmenorrhea, which are incident to chlorosis, 
spasmodic dysmenor- Here the most sensible and successful plan ot 
rhoca - treatment is to address our remedial measures 

to the cure of the stricture of the uterine cervix, upon which the 
nervous symptoms depend for a local cause. We may give bella- 
donna, gelsemium, caulophyllin, or some analogous remedy. 
The warm sitz-bath, or vaginal injections of warm water, may 
facilitate the flow, and relieve the suffering and the remote ner- 
vous symptoms at the same time. But if the spasm of the cervix 
is particularly obstinate, I know of nothing to compare with the 
careful and appropriate use of the sponge-tent. 

Much relief may sometimes be afforded by domestic adjuvants. 
In case of spinal irritation and tenderness, the back may be sponged 

once daily with salt and water. Friction along 

the spine is sometimes very useful. For the 
relief of local neuralgic pain, in the side and chest especially, the 
part may be covered with a layer of cotton batting, oiled silk or 
flannel. If the pain is very acute, dry heat will suffice. If it is 
rheumatic, the local use of hamamelis may be prescribed. 

The diet should be selected with great care. It should consist 
of digestible and nutritious articles, both animal and vegetable. 
If the patient has a distaste for meat, she may cultivate an appe- 

*Quarterly Journal of Psychological Medicine, etc., Vol. III., p. 417. 



112 THE DISEASES OF WOMEN. 

lite for it* by beginning with salt meat, of some kind, as, for ex- 
ample, cod-fish, mackerel or herrings, dried beef, 
lean ham, and the like. Or sea-food, as oysters 
or other shell-fish, may be taken. Eggs or milk prepared in vari- 
ous ways, may tempt the appetite. Bread from unbolted Hour, 
animal broths, chocolate or malt liquors, may be chosen. She 
should not be ordered to ride or to exercise upon an empty 
stomach. 

Moderate exercise in the open air is indispensable. Riding, on 
horseback or otherwise, is preferable to walking or performing 

manual labor. And when your chlorotic pa- 
Exercise and travel. ...... . . 

tients o-o for an airing m their carriage, be sure 

they have the light as freely as they have the air. These hot-house 
productions need it as much as the pale plants that have grown in 
the cellar. Boating, billiards, croquet and calisthenics may be 
very useful. But best of all is a change of scene and surround- 
ings. If to these can be added the health-giving influence of 
cheerful society, so much the better. These hygienic means will 
frequently accomplish more than our best chosen remedies. Sea- 
bathing has its advocates, and mineral waters, especially those 
which are chalybeate, are strongly recommended. 

Whatever the cause may have been, it should be removed, and 
the utmost pains taken to keep the patient from under the do- 
minion of all perturbing influences. Marriage is sometimes salu- 
tary, but is of questionable utility, excepting where the attack 
has resulted from disappointed love. 

Miss will take a small powder of the citrate of iron and 

strychnia, 3d dec. trituration, twice daily, with out-door exercise 
and a generous diet. 

At the end of one month, the menses made their first appear- 
ance. She had much pain, with scanty flow. The second period 
was regular, the flow free enough, with little relative suffering. 
The headache and cardiac symptoms had entirely disappeared ; the 
skin became natural; the lips and cheeks had resumed their prop- 
er color. She took no other remedy. 



LECTURE VII 



AMENORRHEA. 



Amenorrhea.— Delayed menstruation— Etiology of — Symptoms of— diagnosis— prognosis 
and treatment— Suppressed do.— etiology. Case.— Symptoms, diagnosis and treatment. 
Case.— Special indications for remedies— Retention of the menses,— etiology, symptoms, 
diagnosis, prognosis and treatment, both medical and surgical. 

During menstrual life, or between the ages of fourteen and forty- 
five, in this country, there are only two conditions in which the 
non-appearance of the menses can be considered 

A physiological and a 1 

pathological arrest of men- healthy. Ihese are chirms' pregnancy and 

struation. / . _ S 1 & J . 

lactation. Under other circumstances, 11 this 
function is not properly performed the woman is not well. There 
is, therefore, a physiological and a pathological arrest of this func- 
tion. I shall speak only of the latter this morning. 

The word Amenorrhcea is used generically. It signifies a class 
of affections which are characterized by an absence of the men- 
strual flow. It includes (1) delayed meilStriia- 
Definition and varieties. 

tion ; (2) suppression ot the now ; and (3) re- 
tention of the same. Let us consider these several conditions sep- 
arately. 

1. — DELAYED MENSTRUATION. 

This derangement consists in the non-performance of the men- 
strual function, in one who has arrived at the age of puberty. It 
is the emansio mensium of the old authors, and 

Emansio mensium. : „ 

should not be confounded with a mere suspen- 
sion of the flow in one who has menstruated before ; neither with 
tardy menstruation in the case of women who are " irregular/' 
The young girl has reached the age of fifteen, or perhaps of 
eighteen, or twenty, but this function is not yet established. 
For some reason the first appearance of the catamenia is delayed. 
Etiology. — This irregularity is often chargeable to defective de- 
velopment. The epoch of puberty has not really arrived. She is 
yet a child. Her eye lacks expression, her 
manners are less sprightly than they should be, 
und her movements do not indicate the graceful mobility of her 

8 113 



114 THE DISEASES OF WOMEN. 

sex. Her form and features, her carriage and bodily functions, 
do not assume their proper proportions and characteristics. She 
lacks individuality. She is masculine. Her womanly traits are 
not matured. Her health and her fecundity are implicated by 
this delay, and it becomes a serious matter to study into its causes 
and to treat it property. For not only does her welfare concern 
her individual self, but also that of her relatives, of friends, and 
of society at large. 

Delayed menstruation may be due to organic causes, as for ex- 
ample, to congenital absence of the uterus, the ovaries, the Fal- 
lopian tubes, or even of the vagina. Or itmav 

Congenital defect. . _ ° J 

be caused by inflammatory adhesions which 
have taken place at an early age in some portion of the genera- 
tive intestine, or outlet. In some cases it con- 
madcL" 6 ' 111 ^ ° f inflam " stitutes an idiosyncrasy. In certain families 
the establishment of this function will in every 
instance be delayed until the subject is fifteen or twenty years old. 
Its first appearance is greatly influenced by external circumstan- 
ces and surroundings, education, exercise, and associations. But 
more frequently its delay depends upon a de- 

External conditions. .. .... _ 

praved condition of the general health. In 
many cases there is a developing dyscrasia, as for example, tuber- 
culosis, which interferes with and interrupts the coming on of the 

menses. Weakly, scrofulous, chlorotic girls are 

very liable to this form of amenorrhcea ; and 
in the great majority of cases of this kind you will note that the 
effect is likely to be taken for the cause. In all of them the gen- 
eral tone and strength are lowered, the digestion impaired, the 
blood is vitiated or impoverished, and there is atony, debility, 
and torpor of the various functions. 

Symjrtoms. — It is not unusual, in this form of amenorrhcea for 
the patient to complain regularly each month of the symptoms 

that usually attend upon the flow. She may 

Symptoms minus the flow. . ' ' . . 

have pain in the small of the back, dragging in 
the loins, aching across the hips, weariness of the limbs, severe 
and protracted headache, malaise, anorexia, and constipation. 
These symptoms may come and go with the regularity of the 
proper " period," but without the characteristic and necessary 
discharge. Sometimes they are followed by a vicarious hsemor- 



AMENORRHEA. 



115 



rhage from the nose, the eyes, the ears, the lungs, the stomach, or 
the bowels. Or the proper flow may be substituted by a vicarious 
leucorrhcea. 

Delayed menstruation is especially significant in girls who are 
predisposed to any form of phthisis. In them it implies a de- 
praved cachexia, a low state of nutrition, and 

Complicated with phthisis. ,.,.,. . -, . -. 

a great liability either to haemoptysis, or to the 
development of a harassing cough and hectic, which are the pre- 
cursors of serious disease of one or more of the respiratory or- 
gans. If such an one who has passed her fourteenth year with- 
out ever having menstruated, has a cough, or dyspnoea, habitual 
or frequent sore throat, hoarseness, or pain in her side, it should 
be regarded as' a sign of ill health, and of impending evil, and 
measures should be immediately taken for its relief. But, you 
should remember, that great harm may be done 
"Forcing medicines " in- j n these cases by the use of " forcing medi- 
cines," which are given indiscriminately, and 
are designed to compel the flow regardless of consequences and 
of the general condition upon which the disorder depends for its 
cause. 

Diagnosis. — The diagnosis is not usually difficult. As a rule 
(to which, however, there are occasional exceptions,) conception 
before menstruation is impossible. You will, consequently, have 
less trouble in diagnosticating this form of amenorrhcea from preg- 
nancy than in case of suppression or of reten- 
tion. In delayed menstruation from organic 
causes there are no changes in the physical development of the 
person as in puberty. The mammae are small and rudimentary, 
the figure is gaunt and not graceful, and, therefore, the chief pre- 
sumptive, as well as the positive, signs of pregnancy are lacking. 
There are no changes in the uterine cervix, or in the size of the 
womb, and there is no abdominal tumor, as in gestation. The 
lapse of time does not alter the case, or relieve it by limitation. 
The incidental diseases are different. The monthly cycle may 
or may not be recognized in either case. 

Nevertheless, since it is possible that a girl ma} r become preg- 
nant before ever having menstruated, or, in- 
deed, after her menses have been delayed for an 
unusual length of time, and before their final appearance, it will 



116 THE DISEASES OF "WOMEN. 

be best for you to qualify your diagnosis. Else it may happen, 
after all, that the cause of the delay in the catamenia has been a 
very natural and common one, and that she failed to menstruate 
because she was enceinte. A careful physical exploration would 
enable you to decide as to the presence or absence of the internal 
generative organs. 

Prognosis. — The prognosis may depend upon the existence of 
organic defects. Of course, if the uterus were absent or only im- 
perfectly developed, you could not promise a radical cure of this 
disorder of menstruation. And so also of a congenital absence 
of the ovaries, the Fallopian tubes, or of the vagina. 

Where the amenorrhea is attributable to general ill health, or 
to local disease, the prognosis will be that of the dyscrasia, or of 
the disorder, of which in reality the absence of menstruation is 
but a sequence and a symptom. We must weigh the chances of 
recovery from scrofulosis, tuberculosis, gastro-alimentary disease, 
pleurisy, and morbid conditions and alterations of the blood. In 
other words, both with respect to the progno- 

An old and true maxim. ■T 

sis and the treatment, we must remember that 
our patient " is not sick because she does not menstruate, but that 
she does not menstruate because she is sick." 

Treatment. — When you are consulted in a case of this kind you 
should not be inveigled into prescribing at random and indiscrim- 
inately. For many of these cases do not need 

" Let well enough alone." . 

any medicine whatever. It the patient is well 
in other respects, healthy, hearty, with a good appetite, and noth- 
ing to complain of, except that, as her mother or friend will tell 
you, she " has seen nothing," it is best to recommend fresh air and 
plenty of it, sunshine, cheerful society of a mixed kind, travel, a 
change of scene and surroundings, diversion, to take her from 
boarding-school, and afterwards to let Nature take care of herself. 
If she remains well, (and she may do so for months or years,) she 
will be better without medicine than with it. It is time enough 
to prescribe your pellets and powders for her when she can make 
a positive complaint of suffering and ill-health. 

But if, on the contrary, the incipient signs of serious disease 

begin to crop out, you must anticipate and avert 

Anticipative treatment. . 

its lull development. 1 or by so doing you may, 
perhaps, ward off a threatening phthisis, or may save your pa- 



AMENORRHEA. 117 

tient much of suffering from other diseases, and really prolong 
her life. The more chronic and complicated the original affection, 
the more difficult will be the cure, and the greater the need of 
perseverance on your part. 

2. — SUPPRESSED MENSTRUATION. 

I have already said that a practical distinction should be made, 

and borne in mind, between suppression and retention of the 

menses. This distinction is based upon the fact 

A practical distinction. _ 

that menstruation, like other secretory and ex- 
cretory functions, includes two distinct processes, viz. : (1.) the 
secerning, or exhaling, of the elements of a particular fluid from 
the blood ; and (2) the pouring out, or escape of that product through 
a natural duct or outlet. Suppression of the menses concerns the 
former process exclusively. It relates to ovulation, and to its con- 
tingent secretion from the uterine mucous membrane. It is the 
amenorrhee radicale of Raciborski. When, after having been es- 
tablished and maintained for a longer or shorter period, this func- 
tion ceases for other reasons than because the woman has become 
pregnant, is nursing her child, or has passed the climacteric, (un- 
less there is an obstruction of the uterine cervix,) we say that she 
has menstrual suppression. 

Here is an interesting case, the notes of which have been taken 
by our clinical assistant. 

Case. — " About four weeks ago, Miss , aged 20, (late a 

resident of England,) applied at the College Dispensary for re- 
lief from the following symptoms : Cessation of the menses for 
the past four months, constant frontal headache, severe sacral 
pains, pains extending from the sacrum to the scapulae, occasional 
oedema of the feet and ankles, pains occasionally running down 
the limbs, vertigo on going into the open air, and obstinate con- 
stipation. At times, also, she says that she has pains from one 
hip to the other. There is no leucorrhoea, and no epistaxis. She 
states that her mother died at the age of thirty-seven years of con- 
sumption, and that eight of her own sisters have died at about 
twenty-one years of age, after a short illness, presenting the same 
(or nearly the same) symptoms that she has detailed to me. 

" As far as I can learn, there is no hereditary disease on the 
father's side. At the time of their decease, none of the eight 



118 THE DISEASES OF WOMEN. 

sisters who died presented any obvious symptoms of consump- 
tion, but all of them seemed to drop off after suffering a short time 
as this patient suffers. One year ago she was cured in Bristol, 
England, of suppression of the menses of seven months' duration. 
I have prescribed for her three times without relieving anything 
more than the headache, and am led to believe that there must be 
a mechanical obstruction to menstruation (probably malposition of 
the uterus). Excepting a slight flush of the face, which is con- 
stant, this young woman presents no outward symptoms of inter- 
nal trouble, and were it not for her strange story, I should, per- 
haps, be suspicious of pregnancy. The remedy which relieved 
the headache was apis mellifica, but after four dsijs that had no 
effect." 

This patient had menstruated before, and could not therefore be 

suffering from delayed menstruation, as we have just described it. 

She may have retention of the flow, in conse- 

Hereditary tendency to q lience f g me uterine deviation, as the doctor 

suppression. t. 

suspects, but it is hardly probable that each of 
her eight sisters had amenorrhoea from this cause, and all at the 
same age. The very fact that their disease developed at this par- 
ticular age renders it almost certain that they were the victims of 
tuberculosis, inherited from the mother, and that the menstrual 
suppression common to them all arose from this dyscrasia as a 
common cause. For it is not unusual for all, or nearly all, the 
daughters in a family in which phthisis is hereditary, to have this 
disease in a fatal form, when they are twenty to twenty-three 
years old. And amenorrhoea (suppressio mensium) almost always 
accompanies it. 

Suppression of the menses is more common than either of the 
other forms of amenorrhoea. The busy practitioner has to pre- 
scribe for it every day. It may come on sud- 

Course and frequency. in ji , • ;-ii 

denly, or gradually and almost imperceptibly. 
The healthiest and most vigorous women, and especially those 
who are somewhat plethoric, are more likely to have it occur 
abruptly. Leuco-phlegmatic and fleshy women are prone to a 
gradual lessening and final arrest of the flow before the climac- 
teric has arrived. 

Etiology. — The causes of suppression are numerous and varied. 

Perhaps the most frequent is exposure to cold, 

A/voidable causes. . _ . 

as in getting the leet wet, walking, sitting or 
sleeping in damp clothing, improper and extreme change of dress, 



AMENORRHEA. 11^ 

as in leaving off the warm wrappings and flannels of winter, and 
substituting a thin party or ball dress. Taking a cold foot- or sitz- 
bath just before or during the flow is a very common cause of sup- 
pression. Emotional states often induce it. Among them are 
fear, fright, anxiety, mental depression, excess of mental applica- 
tion, the receipt of good or bad news, or solicitude for a sick 
friend, incompatibility in the marriage relation, the worry attend- 
ant upon being a witness at court, and confinement in prison. 

Suppression is incident to attacks of fever, and of local inflam- 
mation, more particularly to ovaritis, endo-metritis, pleurisy, 
pneumonia and enteritis, to the presence of 

Incident to acute disease. t • p 

polypi, fibroids, hydatids and moles. It is often 
due to change of climate. One of my patients has had it for 
three months at a time while visiting the Rocky Mountain region. 
Another, and without any harmful consequen- 
and r tJavei. anse ° c imate ces, every year at the White Mountains. Tak- 
ing a sea voyage may have the same effect. A 
large proportion of the female emigrants arriving in New York 
have this form of amenorrhcea, which may persist for months 
after landing. It may also arise from chlorosis, anaemia and ple- 
thora. It is a species of idiosyncrasy with 

From an idiosyncrasy. 

certain women, now and then to have the 
function of menstruation suspended for a longer or shorter 
time, and afterwards resumed again. The slightest forms of in- 
discretion at the month may suffice to arrest 

From trivial causes. -in m . . 1 Z, 

the now. Taking a drink of ice-water, eating 
a little ice-cream, or indigestible food, or being too much upon 
the feet at the time, may cause it. Hewitt has had occasion 
more than once to observe " that women are liable to have the 
menstrual discharge suspended for one or two periods after first 
going to reside in a house, the staircases of which are of stone and 
uncarpeted, their previous residence having had a wooden stair- 
case only.* 

Chronic and habitual suppression is incident to advanced stages 
of consumption. In some cases, however, it characterizes the 

disease in its incipiency, and may be one of its 

From chronic disease. !L 

first symptoms. You will be consulted for the 

* The Diagnosis and Treatment of Diseases of Women, by Grailly Hewitt. London, 
1863, p. 44. 



120 THE DISEASES OF WOMEN. 

relief of this symptom in young women in whom it is supposed to 
be the chief and perhaps the sole cause of their ill-health. On 
proper inquiry, you ascertain that the patient has a slight, dry, hack- 
ing cough, without expectoration, but Avhich is aggravated by ex- 
ercise. She complains of stitching, lancinating pains in the chest, 
and dyspnoea from the slightest exertion, more particularly on 
ascending the stairs. She is easily fatigued, weak, and has lost 
all relish for substantial food. She has become emaciated, has 
lost in weight, and is more pale than usual. 

These symptoms may have existed for a considerable time and 

developed insidiously, without creating any suspicion of disease 

of the lungs. But if you are observing, you 

Insidious complications. . -i -i • 

will note the order m which they made their 
appearance ; you will learn that, in the majority of cases, the pec- 
toral disorder has preceded the menstrual irregularity. In other 
words, the tubercular deposit, or the pneumonia, was idiopathic, 
while the amenorrhcea is secondary or symptomatic. 

Under these circumstances, the blood becomes deteriorated in 
quality, in consequence of its imperfect aeration and of impaired 
nutrition. All the glandular functions are im- 
dis^a s se ntially a glandular plicated. The ovaries, as well as the mesen- 
teric glands, become diseased, and, if they 
perform their duty at all, do so but very irregularly and imper- 
fectly. If the blood is too poor to furnish the proper elements for 
the gastric juice, for example, it may be unfit to stimulate the 
changes that should occur in the Graafian vesicle, and which 
form an indispensable part of the function of ovulation. 

The intimate sympathy between the lungs and the ovaries, as 

well as the uterus, should not be forgotten. In every case of 

amenorrhcea, there is more or less liability to 

thSr rI °" pectoral sympa " tne development of pectoral disease. In the 

majority, the arrest of the menses predisposes 

to pulmonary haemorrhage. This is the reason why hasmoptysis 

is more frequent among women than among men. And this also 

explains the more tardy convalescence of women from pneumonia, 

bronchitis, pleurisy, and even from pericarditis and endocarditis. 

In many cases the pectoral symptoms and those of scanty or 

suppressed menstruation alternate. Or, with each return of the 

month, there may be a serious struggle, so to speak, between the 



AMENORRHEA. 121 

lungs and the uterus. Here is a case in point, to which I was 
called last evening : 

Case. — Miss , aged 20, has complained since leaving board- 
ing-school, two years ago, of a harrassing cough, which never 
troubles her at any other time excepting at the month. Its com- 
ing on is the precursor of menstruation, and she is satisfied that, 
if she were to lose record of the time in which her catamenia were 
due, she would certainly be notified of the same by this cough. It 
anticipates the flow by some six to twenty-four hours, and sub- 
sides as soon as the discharge comes on. The longer the delay of 
the menses, and the more scanty the flow, the worse the cough. 

Another cause of menstrual suppression was first recognized and 
described by the late Prof. Simpson. It consists in what he 

styled super-involution of the uterus following 
iitfr U u P s er ~ involution ° f the lakor. This abnormality depends upon a species 

of marasmus, or excessive absorption of the 
uterine tissues after delivery, whereby the organ may be reduced 
to one-third of its natural size, and the proper exhalation of the 
menstrual blood from its mucous surface is rendered impossible. 
It is believed that in these cases the said textures undergo a fatty 
metamorphosis, and finally become atrophied and shrunken, as in 
the senile atrophy of those women who have passed the climac- 
teric. Such an organic change would give rise to permanent ar- 
rest of the menses, and, although comparatively rare, might follow 
any case of labor, whether premature or at term. Sub-involution, 
or deficiency of absorption, following pregnancy and parturition, 
is, however, as I shall have occasion to tell you hereafter, much 
more frequently met with. It is intimately related to the clinical 
history of uterine obliquities. 

Symptoms. — The most prominent symptom is the characteristic 
absence of the menstrual discharge, which is itself a symptom, 

and not a disease per se. All the attendant 
s y Sms°dJranJed vascuIar signs signify that some portion of the internal 

generative apparatus, more particularly the 
uterus and the ovaries, as well as the general nervous and vascu- 
lar systems, are in an abnormal condition. Weakness, lassitude, 
aching, constant fatigue, lack of interest in family or social mat- 
ters, indigestion, constipation, headache, cardiac oppression, pal- 
pitation, breathlessness, fickleness, peevishness, fugitive neuralgic 



122 THE DISEASES OF WOMEN. 

pains, hysterical developments of various kinds, accompany 
this arrest of function. Some women suffer from ovarian neu- 
ralgia, others from a species of uterine colic, and not a few from 
cramps or spasms of one or of all the voluntary muscles whenever 
the month comes around and they do not flow. All, except those 
who are really plethoric, have symptoms of asthenia, sedation, 
atony, debility, and general torpor of the bodily functions. They 

become emaciated, bloodless, almost transpa- 
cJxil amenorrhoeal ca " rent, and go into a decline which develops itself 

more or less rapidly according to the original state 
of their health and vitality. In brief, a species of cachexia, which 
soon becomes chronic, and perhaps incurable, follows ; and being- 
complicated with general derangement and ill health, constitutes one 
of the most intractable affections to which women are liable. In ex- 
ceptional cases, however, menstruation maybe suspended for several 
months, and even for years, and finally restored without any 
harmful consequences whatever. One of the members of our 
college class last year cited the case of a woman whom he had 
known who did not menstruate from the age of 46 to 53 — seven 
years. She then menstruated once, and afterwards' became preg- 
nant, and Avas delivered at term of a healthy living child. 

Diagnosis. — You will have more trouble to diagnosticate sup- 
pression from pregnancy than from any and all other conditions. 

This difficulty is increased by the fact, that in 

From pregnancy. . . . 

forming a judgment in a given case, prior to the 
fourth month, we are left entirely at the mercy and caprice of the 
patient. She may tell us that she has incurred no possible risk of 
becoming pregnant, when such is not the tiuth. Or, if she is 
anxious to become a mother, may insist that, nothing but concep- 
tion could have caused the arrest in her case, for she Avas never 
irregular before. Too exclusive a reliance upon her word may 
mislead and deceive us ; but in the first three months, there is lit- 
tle else upon which to predicate an opinion. The reflex and inci- 
dental symptoms, as nausea, loss of appetite, morning sickness, 
swelling of the breasts, are the same. Whatever changes occur 
in the uterine textures in consequence of impregnation begin in 
the body and fundus of the womb. We cannot reach or recognize 
them before the commencement of the twelfth or thirteenth week. 
Subsequent to that period, however the more unequivocal signs of 



AMENORRHEA. 123 

pregnancy begin to develop, and the diagnosis is more easy and 
certain. In doubtful cases, time will help you 
to differentiate between a physiological sup- 
pression of this sort, and one which is in ever} r sense pathological. 
When complicated with retention, you may even have to wait 
until the fifth or sixth, or possibly the ninth, month before you 
can say with certainty whether the arrest of the menses was due 
to conception or to some accidental or morbific cause. 

In simple suppression, however, there is no permanent and con- 
tinuous abdominal development, no tumor, as in retention or in 
pregnancy. 

It will sometimes be difficult to decide whether the non-ap- 
pearance of the flow is or is not due to the " change of life." The 
age of the patient, and inquiries into her family 

From " change of life." . 1 . . 

history may help to settle this question. It she 
is past forty, the irregularity may be due to her age, although wo- 
men do sometimes continue to menstruate much longer. 

One of my patients was " regular*' until her death, which oc- 
curred in her sixty-second year. If the patient's mother and sis- 
ters ceased to menstruate as early as thirty or thirty-five, it might 
modify your diagnosis. Usually, if the suppression is from a 
morbific cause, it is preceded by a failure of the general health, 
and each month the patient complains of symptoms Avhich pertain 
most decidedly to the return of the old habit. But, when the 
climacteric has been reached, and the arrest of the flow is charge- 
able to a physiological arrest of function, the ill health, if there is 
any, follows the change, and the monthly exacerbation does not 
recur. 

Treatment. — You have, doubtless, drawn the proper inference 

with respect to the treatment for this form of amenorrhcea. Cure 

the original, idiopathic disease upon which this 

A cardinal rule. . 

suppression is secondary, and, in the great ma- 
jority of cases, if there be no organic obstacle, this particular func- 
tion will be reestablished. Or as Dr. William Hunter worded it 
in his Lectures, " With regard to the management of the menses, 
my opinion is, that you should pay no regard to them, but en- 
deavor to put her to rights in other respects. If you cure the 
other disorders, you cure the irregularity of the menses, 'which is 
the consequence and not the cause of her complaints" 



124 THE DISEASES OF WOMEN. 

If the suppression is due to chlorosis, ovaritis, metritis, incipi- 
ent tuberculosis, pneumonia, pleurisy, gastritis, hepatitis, rheuma- 
tism, or any other abnormal condition or diseased process, the in- 
dication presented is to cure the primary affection, after which we 
may reasonably expect the secondary one to disappear. Fortu- 
nately we find that remedies are possessed of corresponding rela- 
tions to the various functions. For not only are the bodily organs 
linked in sympathy and susceptibility, but these sympathies and 
susceptibilities have their counterpart in the curative range of our 
remedies. The different sections of a correct and complete 
pathogenetic record are as intimately related as the several cantos 
■of a grand old poem. 

If, therefore, you shall find that the remedy which is manifestly 
indicated for the cure of the complaint upon which the amenor- 
rhea is secondary, is also applicable in case of 

Emmenagogues. . 

menstrual suppression, so much the better. But, 
as between prescribing pulsatilla, or senecin, or any of our medi- 
cines as emmenagogues merely, or iron, secale cornutum, and aloes 
in ponderous doses with the same end in view, there is really no 
difference. Both methods are unphysiological and harmful. 

Abundant experience has satisfied me that the calcarea carbon- 
ica is, perhaps, the most prominent and useful remedy for the re- 
lief of those menstrual irregularities which are 
±ions^ pec ° mp lca " incident to pectoral disease. It seems especially 
appropriate to complicated cases of pulmonary 
and uterine disorder in weakly, ill-conditioned females of a scrof- 
ulous diathesis, with amenorrhea, an impoverished state of the 
blood, and a depraved condition of the nutritive system. 

Pulsatilla is indicated in women with light hair and blue eyes, 
who are weakly, pale, and delicate, of mild and amiable disposi- 
tion, and who are tearful and prone to melan- 

For suppression alternat- -it t, • . . -,-, , -, 

ing with ophthalmia. enoly. it is sometimes an excellent remedy in 

case of menstrual suppression complicated with 
ophthalmia. My attention was called to this fact some years ago 
by my excellent friend the late Dr. Lyman Kendall, of this city, 
who related the following 

Case. — Mrs. , aged 32, had suffered frequent attacks of 

amenorrhea, which persisted for from three to six months at a 
time. The suppression came without any apparent cause, and 



AMENORRHEA. 125 

the return of the flow did not seem to be influenced in the least 
by any medicine which she could take. Her general health was 
good. She had never been sick in bed, and suffered no ill conse- 
quences of the amenorrhcea, excepting an intractible and trouble- 
some inflammation of the eyes. Upon inquiry it was found that 
this inflammation came and went regularly, alternating with the 
amenorrhcea. When the catamenia were prompt and regular the 
conjunctivitis disappeared altogether ; but when they were sup- 
pressed, the eyes became inflamed again. There was redness and 
swelling in the lids, lachrymation in the open air, and irritation 
and pressure as from sand in the eye. Pulsatilla 6, cured both 
these affections promptly and permanently. 

Since almost any of our remedies may be indicated in special 
cases, I will cite the more prominent among them as they are 
related in a curative way to the various causes of amenorrhcea : 

From taking c*o/c?.---Belladonna, gelsemium, puisatilla, dulca- 
mara, chamomilla, caulophyllin, or macrotin, gelsemium, sepia, 
sulphur, rhus tox, 

From check of perspiration. — Cuprum, chamomilla, aconite. 

F) % om changes in the weather, cold and dampness. — Dulcamara, 
rhus tox., rhododendron, nuxmosch., puisatilla. 

From taking cold by getting the feet ivet.-^ Aconite, puisatilla. 

With leucorrhoea. and constipation. — Alumina, natrum mur., 
sepia, graphites, collinsonia. 

F'om fright . or chagrin. — Aconite, lycopodium, coffea, opium 
veratrum vir. 

Irom atony of the uterus and ovaries. — Aletris far., caulophyllin, 
helonias. 

From mental causes. — Aurum, cimicifuga, lycopodium, ignatia, 
veratrum alb., aconite, puisatilla. 

From defective nutrition. — Aletris far., natrum mur. 

With congestion of the head and face in plethoric women. — 
Glonoine, aconite, belladonna, gelsemium, sabina, sulphur, 
opium. 

With eruptions here and there, oozing out a sticky fluid. — Grap- 
phites. 

With eruptions ivhen the menses should appear. — Carbo veg. f 
dulcamara. 

With prolapsed or ante-verted uterus. — Lilium tigr., collin- 
sonia. 



126 'J HE DISEASES OF WOMEN. 

With spitting and vomiting of blood at the menstrual period. — 
Phosphorus, belladonna. 

With corrosive leucorrhcea in place of the menses. — Ruta grav., 
silicea, sepia, arsenicum, cocculus. 

When the menses are suppressed immediately on their appearance, 
returning again to be again suppressed, intermitting menstruation. 
— Sabadilla. 

In thin married women, with forcing pjains in the uterus. — Secale 
cor., caulophyllin. 

With nervous headache and hysterical affections, with cold hands 
and feet. — Veratrum alb., macro tin. 

With painful pressing doivn as if the menses would appear. — 
Platina, belladonna. 

Chlorosis, with bloated, waxy face. — Apis mel., arsenicum, 
mercurius, plumbum. 

With pain in the ovaries just before or during menstruation. — 
Apis mel., Phytolacca. 

In young girls with a tendency to bloating of the abdomen and of 
the extremities. — Apocynum. 

With epistaxis. — Sulphur, bryonia, veratrum alb. 

With a frequent tendency of the blood to the head, with vertigo 
and buzzing in the ears. — Calcarea carb., china, ferrum. 

With p Kile face, blue margins around the eyes, and headache with 
nightly aggravations. — China, cuprum, ferrum. 

With cardiac palpitation and spasm. — Cuprum, lachesis, cimi- 
cifuga, apis mel., nux mosch., bryonia, kali carb., iodium, lilium 
tig., causticum, or aconite. 

With rheumatism or neuralgic pains in the head and face. — 
Gelsemium, macrotin. 

With indigestion. — Kali carb. for sour eructations, with fugitive 
shooting, abdominal pains; nux vomica, arsenicum alb., podo- 
phyllum nux mosch., lachesis. 

lor retarded or suppressed menstruation. — Dr. Holcombe* extols 
the value of senecin in the first decimal, or the first contesimal 
trituration for cases of this kind. He gives a powder every night 
for four months. 

With obstinate constipation at the month, with a discharge of 

*The United States Medical and Surgical Journal, Vol. VIII,, p. 44. 



AMENORRHEA. 127 

almost clear water in lieu of the menses, and an acrid, corrosive 
leucorrhoea, silicea. 

With abdominal tympanites — Belladonna, phosphoric acid, 
chamomilla. 

With dropsy — Apis mel., for incidental anasarca, swelling 
of the feet, pnffiness of the cellular tissue ; helleborns, for ab- 
dominal dropsy, with scanty flow of dark-colored urine ; arseni- 
cum. Dr. G. W. Barnes* reports " invariable success with apo- 
cynum can. in quite a number of cases of amenorrhcea in young 
girls, attended with bloating of the abdomen and extremities." 
He also had "good success with it at least in one case of this dis- 
ease in which the latter symptoms were not marked." 

With chorea, hysteria, etc. — Belladonna, gelseminum, Pul- 
satilla, macrotin, hyoscyamus, coffea, ferrum cit. et strychnia (in 
the 3d dec. trit.), cocculus, cuprum, causticum. 

I am aware that these hints are more suggestive than satisfac- 
tory. Their chief value consists in the possibility that they may 
help you to decide between two or more remedies which, other- 
wise, might seem to be equally appropriate, and in this manner 
serve a good purpose. As a rule, however, in 

A practical hint. ,.-,'. 

functional amenorrhcea, * which is consequent 
upon different morbid states, whether they are acute or chronic, 
the symptoms proper to those conditions, and which would be 
your guide if there were no suppression, will indicate the remedy 
or remedies that are especially indicated. 

But if the suppression is idiopathic (which is comparatively 
rare), you will naturally seek to stimulate the functional activity 

of the ovaries, and of the uterine mucous mem- 
ber idiopathic suppres- ^^ rj^ mfty ^ accomplislied W i t h Ut the 

use of harsh emmenagogues. Pulsatilla, sepia, 
calcarea carb., podophyllin, apis mel., natrum mur., ferrum, china, 
phosphorus, sabina, sulphur, platina, or, among the newer reme- 
dies, senecin, collinsonia can., and the asclepias in., are sometimes 
gWen with excellent result. Dr. C. D. Williams reports some 
remarkable cures with xanthoxylum.f 

* Hale's New Remedies, 1867, p. 83. % United States Med. 

and Surg. Journal, October, 1871, p. 35. 



128 THE DISEASES OF WOMEN. 

The general treatment is sometimes even more important than 
the special. In the temporary suppression which frequently fol- 
lows marriage, a single coitus, or change of cli- 

General treatment. . . " 

mate and occupation, it you are careiul not to 
overdo in the matter of dosing, and will take pains to correct the 
patient's habits, the function will regulate itself. In every case, 
she should take the fresh air daily. Walking, or riding in the 
sunshine, cheerful society, keeping the feet warm and dry, diver- 
sion, and a proper and nourishing diet, are useful auxiliaries to- 
wards a cure. They will help to restore the vital conditions 
which are inherent to this function, and indispensable for its 
proper performance. And they will also fortify the system 
against a degree of asthenia which is quite incompatible with 
ovulation. 

In those who are predisposed to an arrest of the menses great 
care should be taken at the month lest a slight indiscretion or 

exposure induce it. With some women all that 

At the month. . . _ 

is necessary is for them to lie down and keep 
tolerably quiet and passive for one or two days. In others the 
flow will need prompting by appropriate internal, remedies given 
in anticipation thereof ; by the foot or sitz-bath ; by an enema of 
tepid water thrown into the rectum ; or by the introduction of the 
sponge-tent through the uterine cervix some hours, or perhaps 
the night before the flow is due. In some cases the passage of the 
uterine sound, or probe (which, if there is no uterine deviation, 
is not difficult at this period), may, by irritating the os uteri, pro- 
duce the same effect. The habit of taking spirits, as gin or 
whisky, and hot drinks, herb teas and the like, should not be 
encouraged, for the indirect effect of such palliatives is to unhinge 
the nervous system and to increase the difficulty. 

3. — RETENTION OF THE MENSES. 

In this form of menstrual irregularity there is a preternatural 
obstacle to the escape of the flow. Ovulation has been properly 
performed ; the secretion or exhalation of the menstrual blood 
from the uterine mucous membrane has been poured into the 
cavity of the womb, but there is no outlet for it. Either the 
canal of the uterine cervix, or the vagina, or both these portions 



AMENORRHEA. 129 

of the generative intestine, are closed, and there is no means of 
escape for the periodical discharge. 

Etiology. — Menstrual retention may be caused by atresia of the 
cervix uteri, resulting from post-partum inflammation or from 
cauterization ; spasmodic closure of the os in- 
ternum ; flexures and obliquities of the womb ; 
the presence of polypi, or of coagula, which serve to obstruct the 
passage ; atresia of the vagina ; or closure of the same by an im- 
perfect hymen. In exceptional cases it may be due to a species 
of uterine inertia. Here the flow exudes passively, but the 
condition of the patient's general health is so low, and the uterine 
fibre is so irresponsive to ordinary stimuli, that the peristaltic 
action of the womb is not aroused as it should be. The force that 
is designed to unlock the internal os and to expel the menstrual 
product is not called into exercise. The secretion is lodged, and 
there is no " show." 

Symptoms. — In this class of cases, the menstrual molimen is 
more or less pronounced. The symptoms are those which accom- 
pany normal menstruation, always excepting 

The form without the flow. . no i i t» • 

the sanguineous now from the vulva, rams 
in the back and loins, around the pelvis, and down the thighs and 
limbs, bearing down and fullness within the pelvis, forcing pains, 
which are aggravated by standing or walking, headache, malaise, 
chills, nervous tension and perturbation, and sometimes dyspnoea, 
and diarrhoea or dysentery, recurring with some degree of regu- 
larity, may lead the patient to suppose the discharge is coining 
on, After a longer or shorter interval, however, these symptoms 
subside, and the effort to establish the flow has proved abortive. 
This state of things may continue for months, and even for years, 
to the manifest detriment of the general health. 

Diagnosis. — Proper retention of this flow can only occur in 
those who have menstruated before. For this reason, it could not 
be readily confounded with, or mistaken for, Delayed Menstrua- 
tion. The repeated efforts to expel the secretion, at each return 
of the monthly cycle, the kind and degree of suffering experi- 
enced, and the special clinical history of the case, would help you 
to differentiate between this form of menstrual derangement and 
a case of suppression, and also to diagnosticate it from " change 
of life," and from pregnancy. 



130 THE DISEASES OF WOMEN. 

Prognosis. — The prognosis will vary with the cause of the dis- 
order, the age of the patient, and the condition of the genera] 
health. Other things equal, a recent case is more promising than 
a chronic one. If the blood has become deteriorated in quality, 
either from depraved nutrition or from the resorption of post- 
organic matters confined in the cavity of the uterus, more serious 
consequences are to be apprehended. Or if, in consequence of 
the damming up of the discharge, the ovaries have become seri- 
ously diseased, we would not promise a prompt and radical cure 
to follow the restoration of the menses. For in exceptional cases 
the removal of the obstacle to the menstrual discharge, whatever 
it may have been, fails to re-establish this very important function. 

Treatment. — -The prime indication is to remove the cause of the 

retention. Atresia of the cervix can usually be overcome by the 

careful and persistent employment of the uterine 

Surgical means. . ' 

sound, or probe, Friestly s or Atlee s dilators, 
Simpson's ebony bougies, and the sponge tent. In rare cases the 
hysterotome may be requisite. I could cite many cases in which 
these means have cured retention of the menses due to atresia of 
the neck of the womb, occurring as a consequence of lying-in, 
and of excessive cauterization. 

When the trouble depends upon spasm of the internal os-uteri, 
the same dilatation may be necessary, but it should be conjoined 

with such internal and hygienic treatment as is 

Dilatation, etc. . 

suited to overcome the tendency to locai and 
general spasms. Here you will need to counteract the hysterical 
bias of the patient, and to place her under conditions which favor 
recovery. The topical and general use of electricity promises to 
be of great value in this particular class of cases. 

If the uterus is bent, or twisted upon itself, proper means must 
be taken to correct and cure the deviation. The most frequent 

of these displacements is retro-flexion, the womb 

Reposition of the uterus. . -i ti i i i j? , i 

being curved like a retort, and the canal 01 the 
cervix obliterated at the point at which the body of the organ is 

bent upon its neck. These cases are very tedious, but if you are 
really skilful, you will succeed in curing a large proportion of 
them. 

Polypi and coagula are to be removed by excision, and by 
dilatation of the canal of the cervix. Atresia of the vagina will 



AMENORRHEA, 



131 



require a caieful dissection of its adherent mucous surfaces, after 
which the freshened edges must be separated 
and n of S !he h SliT™*' either by an oiled tampon or Sims' dilators, until 
they are healed. If the hymen is imperforate, 
it must be divided in order to discharge the contained fluid. The 
old plan was to make a crucial incision into this septum in such a 
case ; but, serious results having followed the too rapid evacuation 
of the fluid, modern authorities advise that the cut shall be valve- 
shaped instead. 




Fig. 20. Sims' Vaginal Dilator. 

If the retention is referable to uterine atony, the general health 
must be built up and fortified, and local excitation and stimula- 
tion of the womb secured by electricity, bathing, frictions along 
the spine, and the use of remedies suited to the especial and inci- 
dental symptoms, whatever they may be. 



LECTURE VIII. 



AMENORRHEA — CONTINUED. 

Amenorhcea, with prolapsus uteri and obstinate vomiting. Case.— Resembling perforating 
ulcer of 1 he stomach— reposition of the uterus, — subsequent history.— Note,— Amen- 
orrhoea with choreic spasms. Case,— remote disease from an arrest of the menses,— 
"forcing- the now,"— effect of rest and quiet,— Amenorrhea with supra-orbital neu- 
ralgia. Ca<e — varieties of menstrual neuralgia,— lo al and specific treatment.— 
Spinal irritation with amenorrhwa, convulsions, etc. Case.—Amenorrhoza in advanced 
phthisis. Case. 

We will continue the study of amenorrhea. The notes of the 
first case concern one of my private patients, and were written by 
the woman herself. The case is one of 

AMENORRHEA, WITH PROLAPSUS UTERI AND OBSTINATE VOMITING. 

Case. — I am 22 years of age, and married ; have been ill with 
an intractable gastric difficulty at intervals for six years. This 
affection first manifested itself after a severe attack of diarrhoea, 
which was followed by spitting up of the food while it was parti- 
ally digested, or still unchanged. This symptom used especially 
to trouble me in the evening, after supper, but sometimes fol- 
lowed the other meals also. Coffee, pastry, and all rich food, 
new vegetables, and many kinds of fruit, were the first articles to 
be rejected by my stomach. Consequently, my diet was reduced 
to meat and bread. For a time all kinds of fresh meat were well 
borne, but finally beef-steak was the only one that would be tol- 
erated. 

The first attack of this indigestion came on late in the summer 
and continued for several months. It returned the next year at 
the same season, and lasted until the middle of the following 
winter, being accompanied by three months of suppressed men- 
struation. These combined troubles occasioned severe headache, 
and bloating of the stomach and the abdomen. However, I rap- 
idly gained in flesh, which was soon lost when the menses 
returned. The next season I derived much benefit from a resi- 
dence of nine months in Saratoga. After drinking its waters I 
returned home with my disease apparently cured. Two years of 
comparative health followed, with occasional symptoms of the old 
trouble, which were generally relieved by the regulation of my 
diet. 

The third attack was preceded, accompanied and followed by 

132 



AMENORRHEA — CONTINUED. 133 

bilious fever and dysentery, with which diseases I was very ill for 
several weeks. The gastric difficulty did not leave as usual in 
the winter season. The symptoms continued for more than a 
year, the nausea and vomiting increased in frequency and vio- 
lence, and were accompanied by great acridity of the matters 
ejected, distress and burning. I could compare the feeling which 
predominated to no sensation except to that which would be pro- 
duced by many pieces of apple-core moving about in the stomach. 
Constipation and bloating of the abdomen were constant symptoms. 
Medicine seemed powerless ; one article of diet after another was 
abandoned ; my strength gradually decreased ; I became nervous ; 
my nights were wakeful, with unpleasant dreams, and a dumb 
ague at last set in. Meat and other solid food could not be toler- 
ated by my stomach, and soon the entire system yielded to utter 
prostration and debility. 

The region of the stomach now became very hard to the feel, 
but extremely sensitive to the touch. For seven months menstru- 
ation was entirely suspended. From September to the middle of 
December, I became weaker and weaker. I then began gradually 
to improve, but the vomiting continued nearly every day for 
about four months longer. For six months I had eaten no solid 
food whatever, but had subsisted on porridge and farina. For two 
months I lived exclusively on milk, and a weak strained broth. 

The first discharge of matter or pus by vomiting took place in 
September, and from that time on I continued to raise it. In 
November this matter became more copious, and was thrown up 
as often as every hour in the day. The most abundant of these 
discharges of pus were preceded by sinking spells, with difficulty 
of breathing and numbness. Beside this matter there was also 
vomited a clear fluid which made the throat, mouth and lips burn 
and smart severely. But a thick froth resembling the beaten 
white of an egg^ generally accompanied the pus. 

Intense nervousness, wakeful and often sleepless nights, and 
severe pains in the head, and also in the back and hips, racked 
my delicate constitution terribly. For six months, with but a few 
exceptional days, the vomiting spells followed each other every 
one to six hours. I was entirely confined to my bed for four 
months. 

This was the condition in which I found this patient on my first 
visit. She was a bride of a few months. Her husband and family 
were extremely solicitous concerning her, for, excepting that at 
times she had a rosy English complexion, she really appeared like 
one who could not live very long. Further examination of the 
case from time to time, as she could bear it and as opportunity 
offered, elicited the following additional symptoms : 



134 THE DISEASES OF WOMEN. 

A large portion of the time, during which she suffered from 
these attacks of vomiting, the appetite was craving and almost 
ravenous. This was accompanied by extreme depression of 
spirits. For several months after the vomiting came to be of 
almost daily occurrence, there was little or no loss pf flesh, the 
cheeks were red and the eyes bright as in perfect health, but the 
complexion had a peculiar bluish hue, especially in the morning. 
The feet and hands, which at other times were almost as cold and 
colorless as marble, became hot and burning. The perspiration 
had a strong, disagreeable odor. This odor was especially bad 
when the vomiting of pus was most frequent and copious. For 
many weeks the stomach was so sensitive that she could tell the 
moment the food entered it, and in what part of the organ it was 
lying. A marked and peculiar feeling for months prior to her 
illness was that of a sharp distress (the "■apple-core" sensation) 
just at the entrance to the stomach. This was accompanied by a 
feeling of faintness from lack of food, which eating only increased. 
Each of these attacks was characterized by a more or less pro- 
longed arrest of the menses. She also complained of weakness 
and lameness in the small of her back and hips, Avith dragging 
down sensations, occasional dysuria and obstinate constipation. 

My first impression of the pathology of this case was, that it was 
.one of perforating ulcer of the stomach, and, as you may suppose, 
my prognostications were very cautiously given. 
prolapsus the exciting My second visit disclosed the menstrual com- 
plication, and the third interview decided me 
to request an examination per vaginam. It was accordingly made. 
I found the vulva in a state of hypersesthesia, with considerable 
constriction of the vaginal orifice. The uterus was prolapsed 
upon the floor of the pelvis, and exquisitely tender to the touch. 
After a little delicate manipulation this organ was lifted as far 
toward the superior strait as possible, and the patient directed to 
lie for the most part upon the left side. 1 prescribed mix vom- 
ica 3 , a dose to be taken every three hours. 

The next morning her pelvic and sacral pains had vanished, 

the headache was relieved, the vomiting had been less frequent, 

and she was hopeful. In brief, she kept to her 

^Effect of replacing the j^ for ^^ ^^ weekg mQT ^ Qn accQUnt Q f 

the prolapsus, and also of the menstrual flow, 
which returned within a fortnight. Once in four or five days the 
womb was restored, in case it had fallen, with the index finger. 
Calcarea carbonica 3 was the only remedy that she took after the 



AMENORRHEA CONTINUED. 135 

first few days, excepting caulophyllin and coffea, which were 
given incidentally to promote rest and sleep. Menstruation soon 

became regular and normal in every respect. 

The gastric difficulty lessened until almost any 
kind of food could be taken, relished and retained. Her " dumb 
ague" disappeared, and her old flow of spirits returned. In a few 
weeks her health was perfectly restored. In six months she 
became pregnant, and now she has a bright, healthy child, which 
is about a year old. She passed through gestation without any 
morning sickness or vomiting ; and through labor and lactation 
with no untoward or unusual symptoms. Two years have elapsed 
and there has been no return of her disease. 

My object in reporting this case is not to reflect upon either of 
the physicians who preceded me in its management, but to make 

a few practical points that will be available to 

you bye and bye as practitioners. The first of 
these is that your skill in diagnosis, and your success in treatment 
will depend upon the thoroughness with which you examine and 
analyze the case in hand. Much has been said of the importance 
of the " totality of the symptoms" as the basis of treatment. In 

a knotty, complicated case like this, the " total- 
toms T ° tality ° f the symp " % of the symptoms" includes a great deal. It 

classifies and arranges the gastric, the alimen- 
tary and the nervous symptoms as the more prominent and sug- 
gestive; but it is found that those physicians who claim to pre- 
scribe in accordance therewith are very apt to overlook the 
menstrual and uterine complications, or, at least, they do not 
always give them their due prominence. And this fact explains 
some of their failures. For if we should place undue stress upon 
the character of the matters ejected, or the frequency and other 
peculiarities of the vomiting, as interpreting the nature of the 
disease, and as indicative of the remedy, which is characteristic 
and most appropriate for its relief — the result would be that our 
pathology would be at fault, and our therapeutical progress would 
take the Avrong direction. 

In a case of this kind it is sometimes very difficult, and even 

impossible to decide which class of symptoms 

The cardinal symptoms. . „ 

is really the most significant. It our judgment 
concerning them is based upon their objective consequences, and 



136 THE DISEASES OF WOMEN. 

not upon their subjective cause and relation, we shall be very 
apt to declare in favor of the former. Hence, it frequently 
happens that the most clamorous signs get the credit of being 
characteristic and sufficient when, in fact, they are not so. 

This is a case in point. The uterus was badly prolapsed, and 

evidently had been each time that she had suffered from the 

gastric derangemento The cause of her illness 

Practical deductions. . 

was mechanical and, while it acted, was con- 
stant in its operation. The reflex functional disorder of the 
stomach was so severe and long-continued that it finally developed 
into an undoubted ulceration of that organ. But even when the 
symptoms connected with that ulceration were at their worst, 
there was nothing distinctive in them either as to the cause of 
the difficulty, or the best mode of curing it. 

The second proposition is that while we are careful not to 
exclude some of the symptoms arbitrarily, or through neglect, we 

should not exalt others to an unmerited pro- 
prc^per t s5mpt d o U rn e s Weight to nrinence indiscriminately, and without good 

reason. The uterine deviation and the men- 
strual arrest were the cardinal peculiarities of the case under 
review. When they were relieved the more remote gastric symp- 
toms disappeared. Now it would not be safe to conclude and to 
insist from this that pessaries and emmenagogues are the best 

means of cure in a case of ulceration of the 
influences proper cUnical stoniach with similar vomiting ; neither to 

declare that these symptoms are invariably 
due to the same, or to any remote cause, whether sexual or other- 
wise. It is the inference we deduce, and the lesson we learn 
from such an experience that interests the profession, and our 
patients also. It is the physician's tact in taking hold of the right 
thread that enables him to unravel the tangled skein of disease. 

And whoever, in a case of utero-gastric disease, can tell which 
is the primary lesion, and which is the secondary one ; which 

symptoms are first in importance, and which 

are not ; will have a key to the choice of the 
treatment proper to these compound cases which he could not 
otherwise obtain. Starting from this point, he may select the 
remedy or remedies, surgical or medical, by a reference to his 
experience , to his library, to his materia medica, or through a 



AMENORRHEA CONTINUED. 137 

species of " unconscious cerebration ;" but lie will gain his object 
more speedily, safely and surely than if he took a less compre- 
hensive view of the case, and always persisted in beginning at 
the other end of the series. 

You will readily understand how the extreme and persistent 

irritability of the stomach, in a case of this kind, might finally 

involve the most serious consequences. When 

in effects of excessive a ii t h e f 00( i that is swallowed is reiected, and 

vomiting. J ' 

the vomiting is so nearly constant, it is impos- 
sible for the patient to be properly nourished thereby. Her 
assimilative functions are sure to be impaired. The digestion, 
the circulation, respiration and innervation cannot escape. And 
thus the general health will be undermined. Organic disease will 
be the indirect consequence, and prostration, debility and death 
may follow. 

Indeed the diseases of any portion of the gastro-alimentary 
mucous membrane are more serious when complicated with uter- 
ine and menstrual disorders than when they 
serious nature of utero- & not C0 -exist. For this reason, in women, 

gastro-alimentary disorders. ' ' 

the worst cases of intestinal derangement, and 
indigestion, constipation and diarrhoea are those which are com- 
plicated with intra-pelvic difficulties of various kinds, as for 
example, uterine displacements, ulceration, chronic cervicitis, 
ovaritis, menstrual retention, leucorrhcea, and menorrhagia. The 
remoteness of these several lesions, — which complicate even 
when they have not caused the alimentary disorder, and the 
absence of any very prominent signs of uterine or ovarian 
trouble, may lead to their being overlooked as prime factors in 
the case. If we add to this that a proper physical examination of 
the pelvic organs is usually the last thing to be thought of under 
these circumstances, you will see how it is possible for such com- 
plicated diseases to resist treatment, and finally terminate fatally. 
These cases vary so much, and are so unlike, that one descrip- 
tion will not answer for them all ; nor will one kind of treatment 
cure them indiscriminately. Whatever the nature of the indirect 
cause, its effect should be counteracted by its removal. Possibly 
not one in a hundred cases of chronic and persistent vomiting 
may depend so directly as this upon uterine displacement. But 



138 



THE DISEASES OF WOMEN. 



the fact that it may happen should not be forgotten, for the very 
case to which you are called may be one of this kind. 

Nor need there be any clashing or mischievous interference on 
account of what may be termed the surgical and the medical indi- 
cations sometimes presented by the same case. 
no?antTd y ot a a n i dmediCiaeTne uterus can be reposited, its cervix dilated, 
or the os uteri medicated topically, if needs be, 
while the constitutional treatment, based upon other and different 
indications, is still being pursued. * 

AMENORRHEA WITH CHOREIC SPASMS. 

This case illustrates the relation of the nervous system to the 
function of menstruation. Sometimes it is next to impossible to 
say whether the menstrual trouble has preceded or followed the 
nervous derangement. But careful study will help to decide this 
very important question. 

Case. — Miss aged 19, of full habit and general good 

health, is almost never ill. Her mother says that four days ago, 
on Sunday last, she took cold while in attendance upon the Mission 
Sabbath School . In consequence of this her menses were arrested, 
and the same evening she was seized with a severe headache, which 
has continued with abated violence clay and night until the present 
time. This pain is described as acute at intervals, extending over 
the whole head, and aggravated by noise and light. The pupils 
are slightly dilated, and the face occasionally flushed. She sees 
objects distinctly, and is rational all the while. Since the onset of 
the attack, however, she has not been able to sleep more than a 
very few minutes at a time. Two hours ago a new train of symp- 
toms was developed. These symptoms have alarmed the parents 
and friends exceedingly, and for their explanation and cure we 
have been consulted. Her relatives are in great dread of paralysis. 

The right hand and arm commenced to jerk spasmodically, so 
much so that at times it became quite unmanageable. Sometimes 
the arm and forearm were thrown about wildly, and then extended 
and flexed quickly and violently. Again, the muscles of the shoul- 
ders were so severely convulsed as to threaten the dislocation of the 
head of the humerus from the glenoid cavity of the scapula. Occa- 
sionally, during these paroxysms, the shoulder is thrown high up 
alongside the head. These movements are involuntary. It is 
quite impossible for the patient to control or suppress them, and 
when they have ceased temporarily she complains of great fatigue 
in the aflected arm and shoulder. The paroxysms recur as often 
as once in five minutes, and, as you will observe, are somewhat 

*Ten years have passed now (1880) since the above record was made, and this patient has 
been well and hearty the whole of that time. The cure seems to have been radical and 
permanent, and the daughter is almost a young lady. 



AMENORRHEA — CONTINUED. 139 

grotesque as well as painful to behold. Excepting the left arm, 
which is but slightly affected, the remaining portions of the body 
and extremities are not implicated. The pulse is only 80, and nor- 
mal in every respect. She urinates freely and frequently, but the 
catamenia have ceased entirely since Sunday. She thinks that when 
the nervous twitching and spasm commenced in the arms and shoul- 
ders the headache became less severe in degree than it was before. 

It often happens that the menstrual flow is suddenly checked 
by "taking cold." Getting the feet wet, exposure from insuffi- 
cient clothing, or from sitting in a draught of air, may induce a 
complete arrest of the discharge. In the case before us this result 
was produced by some such apparently trivial means. 

Practically speaking, there is a distinction between suppression 
and retention of the menses, which you should never forget. Sup- 
pression of this function implies its complete 
Difference between sup- arres t or rather, that the ovaries and the uterine 

pression and retention. 

mucous membrane have failed to furnish the 
products which constitute the true menstrual secretion. Retention 
of the menses signifies that, although the catamenial fluid has been 
secreted into the cavity of the womb, yet, for some especial 
reason, or reasons, its escape has been prevented. In the one 
case it is not poured into the uterus ; in the other it is not poured 
out of it through the vagina. This distinction corresponds with 
that made between urinary suppression and retention. In the 
former, the urine is not secreted, its elements are not selected by 
the renal organs from the blood which is brought to them. In 
the latter, although the kidneys have done their work, the ureters, 
the bladder, or the urethra, are in a condition which obstructs the 
flow and prevents the discharge of their proper product. 

A sudden arrest of the menses, " while the flow is on," is likely 
to re-act either upon the circulatory or the nervous system, or 

upon both together. This is a fruitful source 
a rr^r m n fmen S S se from of m health among women. While this func- 

tion is being performed, it is the easiest thing 
imaginable, by such means, to convert a physiological injection of 
the ovaries, and of the uterine mucous membrane, into a patho- 
logical state of congestion and inflammation. This is a short step, 
and it is taken in a twinkling. The most serious and intractable 
results may follow. Other and remote organs with which the 



140 THE DISEASES OF WOMEN. 

pelvic viscera are in sympathy, may be implicated. Here we have 
evident determination of the blood to the brain, which is directly 
attributable to this cause. Sometimes this result is even more 
pronounced and alarming. There are those in whom the slight- 
est and most temporary arrest of the menstrual flow will induce 
cerebral lesions that threaten to destroy both reason and life. 
Our patient has suffered extremely from symptoms of this kind. 
Fortunately she has escaped the delirium which is usually present 
in such cases. In its stead, however, there is the insomnia which 
implies great nervous perturbation and derangement. 

The spasmodic phenomena have followed indirectly. They are 
symptomatic. In their production it is probable that the cere- 
bellum has been especially implicated. For, 
ph S en?me°nT atic nervous according to Flourens, Dalton and others, it is 
the particular function of that part of the brain 
to preside over and co-ordinate, or harmonize the voluntary mus- 
cular movements. In these choreic jerkings we have evidence 
that this function is disordered. This } r oung lady suffers from 
what has been improperly styled " insanity of the muscles." The 
muscles of the right shoulder and arm are in a state of insubor- 
dination to the will. She commands, but cannot control them. 
Their irregular and forcible action is exhaustive, and it is not 
strange that a temporary arrest of the spasms is accompanied by a 
sense of weariness of the affected parts. Excepting from extreme 
exhaustion, there is no danger of her becoming paralyzed. 

If, instead of the cerebellum, the cerebral lobes were involved 
in this case, there would have been marked delirium, and perhaps 
a mild and self-limited form of mania. Cerebral troubles, depend- 
ent on sudden interruption and arrest of the menses, are apt to be 
characterized by wakefulness, and oftentimes by utter inability to 
sleep. The hysterical peculiarities which this case presents are 
also due to the menstrual complication. 

Treatment. — The choice of remedies for the symptoms just 
detailed and analyzed is between belladonna and gelseminum. I 
prefer the former, because it corresponds more nearly to the 
patient's habit and temperament; to the probable cause of the 
menstrual suppression ; to the brain symptoms dependent on the 
same, in all their minuteness ; and to the reflex spasms of the vol' 
untary muscles of the shoulder and arm. It is better adapted to 



AMENORUHCEA CONTINUED. 141 

the congestive tendency dependent on the arrest of the catame- 
nial flow than any other remedy. If this patient had been seized 
immediately with the spasms ; if the choreic symptoms had devel- 
oped the moment the menses ceased, we would have ordered the 
gelseminum. For, in that case, the suppression would have de- 
jDended on a sudden contraction of the cervix, analogous to that 
which sometimes takes place in labor. And the gelseminum is 
even better fitted to overcome that contraction than the bella- 
donna. But here the nervous symptoms were preceded by an evi- 
dent afflux of blood to the brain. This was the primary lesion, 
and the order of sequence is a significant factor in the choice of a 
remedy for any given class of symptoms. Belladonna not only 
corresponds with the cerebral lesion, but is equally applicable to 
the relief of the muscular symptoms arising from it. 

Precisely what degree of importance should attach to a restora- 
tion of the menses in these cases, it is sometimes difficult to deter- 
mine. The old method was to force their 
to S re°urn > he fl ° w be f ° rced re ^ urn by the use 0I * emmenagogues, cathartics, 
hot herb teas, and the warm bath. And this 
under the impression that the symptoms which had their origin 
in the arrest of the flow could not be so promptly or effectually 
relieved as by its re-establishment. In many cases, where the}' 
were resorted to at once, and if they were not too powerful, these 
means were, no doubt, efficacious. Patients were cured in what 
was called a common-sense sort of way. But where, as in the 
case before you, a considerable time has intervened between the 
cessation of the proper menstrual flow and the making of the pre- 
scription, it is certainly prejudicial to the health and welfare of 
the patient, indeed, unphysiological, to attempt to bring it on 
again. Relieve the indirect symptoms by direct remedies, as 
speedily as possible, and trust to the natural powers to restore 
the function at or near the next "period." Where there is evi- 
dent determination of blood to the head, I can see no valid objec- 
tion to foot and hip baths as adjuncts to our remedies. 

This one thing you may bear in mind with respect to this form 
of amenorrhea. When some exciting cause 
suppressor' trouble from nas suppressed the discharge suddenly, and 
when, after a few hours, or days at the far- 
thest, the flow is not resumed, the chances of trouble at the next 



142 THE DISEASES OF WOMEN. 

"period" will vary with the degree of congestion and inflammation 
of the uterus and ovaries consequent upon that suppression. If the 
mishap has reacted upon these organs exclusively, the mischief is 
likely to be perpetuated in the form of dysmenorrhea, menorrhagia, 
permanent retention, sterility, etc. But if, on the other hand, the 
brain is involved, any subsequent irregularity of menstruation will 
not be so apt to follow. Symptomatic disorders of the nervous 
system, dependent on this variety of menstrual arrest, are self- 
limited, and seldom interfere very seriously with the resumption 
of the floAV at the next and subsequent periods. The importance 
of this rule is shown in the treatment which it is proper to pursue 
under these varying circumstances. In the former case there is 
manifest need of treating the patient during the monthly interval, 
so as, if possible, to avert more serious consequences, and to 
secure the punctual appearance of the accustomed discharge. In 
the latter, the present symptoms should be relieved, and the gen- 
eral system regulated by attention to the diet, and by exercise in 
the open air, after which we may safely leave the rest to nature. 

I might spend the whole hour, most profitably, perhaps, in 
insisting upon the especial need of rest in this class of cases. 
When you visit such a patient, you will very 

Rest and quiet. J . . " .. . , 

likely rind her in an illy-ventilated apart- 
ment, surrounded by a host of anxious relatives, including one or 
more lovers, and neighborhood gossips enough to discourage her 
or drive her crazy, and to consume the oxygen to which she alone 
is entitled. Your first duty, in such an extremity, will be to clear 
the room of its unwholesome contents. If these " friends " are 
adhesive and pertinacious, and you cannot devise any better expe- 
dient, you may quietly hint that these symptoms are very pecu- 
liar, and may possibly develop into some contagious affection, as, 
for exanrple, the small-pox. This will have the effect to scatter 
those mischievous comforters, w T hose sympathy is a curse instead 
of a blessing, arid you can then forbid their return. In similar 
nervous states the most trivial causes may perpetuate the diffi- 
culty. A noisy door-bell, a talkative nurse, too much light, or 
sound, or stir in the room, or house, the doctor's creaky boots, 
and many other things may counteract the- influence of the 
most appropriate internal remedies. It is a very important part of 
your duty to recognize and remove all these obstacles to recovery. 



AMENORRHEA — CONTINUED. 143 

The patient will take a dose of belladonna 3d, once in three 
hours during the day, and we shall see how promptly and satisfac- 
torily she will recover. 

AMENORRHEA WITH SUPRA-ORBITAL NEURALGIA. 

Case. — Mrs. K., aged 36, with light hair, blue eyes, and mild 
disposition, complains of a peculiar form of neuralgia associated 
with the return of menstruation. The menses are tardy; some- 
times delayed one, two, or even three days. Their appearance is in- 
variably preceded by a violent neuralgic pain, which is located over 
the left eye, along the superciliary ridge. This suffering usually 
begins when the flow should commence, and continues with in- 
creasing severity until menstruation sets in, after which it grad- 
ually subsides. In the interval her health is excellent. She has 
never had any other form ol neuralgia, but has been subject to 
this for ten years past. It has never been located over the right 
eye, or in any other than its present seat. She " expects to be 
sick" three or four days hence. 

This case is an anomalous one. It is by no means rare to hear 

women complain of neuralgia which is most troublesome " at the 

month." Sometimes it affects the head, the face, 

Varieties of menstrual the teeth QJ . th& earg T l iere are those who 

neuralgia. 

have occasional attacks of angina pectoris at 
this period. Ovarian and mammary neuralgia are frequent ac- 
companiments of menstruation. Incidental, shifting local pains 
often torment women whose courses are due but are somewhat 
delayed. But a circumscribed neuralgia of this sort, in this par- 
ticular locality, recurring with the regularity of an ague paroxysm, 
in immediate relation with the menses, and subsiding as soon as 
they have commenced, is by no means common. 

A strange peculiarity contingent on all these cases of menstrual 

neuralgia, is that the pain is more likely to be 

seated in the left than in the right side of the 
body. 

Treatment. — These pains are reflex. The cause that produces 
them is a temporary retention of the menses. Remove this cause, 

and the suffering is at an end. This indication 

Local treatment. 

may be met, temporarily at least, by a variety 
of domestic expedients. A. drink of gin, a warm sitz-bath, the 
application of a bag of hot salt to thehypogastrium, the operation 
of a carthartic or an enema, chloroform, or opium, may promote 



144 THE DISEASES OF WOMEN. 

the menstrual flow and arrest the pain. But these expedients are 
only palliative and transient in their effect. They will exert no 
influence over the function at the next period. In anticipation of 
the menses the neuralgia will return again. 

In order to effect a radical cure thereof, we must look to the 
seat and character of the pain, its particular relation to the men- 
strual nisus, whether it comes on, or is worse 

Specific treatment. . . 

before, during, or after the flow, and to like 
symptoms, for especial indications for our remedies. I have never 
seen but one well-marked case of this kind before. It was the 
exact counterpart of this. I gave that woman Pulsatilla 3 The 
flow commenced almost immediately the neuralgia vanished; and 
although five years have elapsed, it has never returned. Mrs. K. 
will take the same remedy three times daily, until the menses ap- 
pear, and I prophesy that she will be free from this unwelcome 
neuralgia in the future. 

SPINAL IRRITATION, WITH AMENORRHEA, VICARIOUS VOMITING AND 

CONVULSIONS. 

I was consulted in the following case by my friend, Dr. Wm. 
D. Foster, of Hannibal, Mo. The notes thereof were furnished by 
the patient, wiio is a most estimable and intelligent person : 

Case. — My parents were born in Vermont, and up to within a 
short period before their death, were very healthy and robust. 
With my mother the " turn of life " came at 53. This caused a 
severe illness, which developed into insanity, and finally termin- 
ated in death from heart disease. My father lived to be 68, and 
died of dropsy of the heart. I was born in Cleveland, Ohio, and, 
when my mother died, was 14 years of age. While visiting Chi- 
cago the same season, I had a severe illness, of which I remember 
nothing, excepting that I had a very sore mouth. Previous to this 
illness, I had always been very well, except that when I was about 
seven years old I was vaccinated, and it made me very sick. I lost 
the use of my left arm for some time ; had swellings in the arm- 
pit and upon the arm, which had to be lanced. 

In the spring of 1862, the corner of a falling door struck me be- 
tween the shoulders, and left me insensible for a day or two. 
Upon recovery I could not see out of my right eye. It did not 
pain me much until I began to recover my sight, which was several 
months after the accident. Often since that time I have been 
troubled with very severe pains in that eye. At these times the 
pupil enlarges, and I cannot see out of it. 

Soon after my illness in Chicago I realized that there was some- 



AMENORRHEA — CONTINUED. 145 

thing wrong with my spine. The physicians predicted that I 
would outgrow it. The pains in the back were almost constant, 
but were very much aggravated whenever there were signs of 
torpidity of the liver, which generally occurred two or three 
times a year. Sometimes I would be prostrated with these 
attacks for from two to four weeks. 

In 1864, 1 was troubled with the passage of gall-stones. Every 
few days I would suddenly be prostrated with dreadful pains in 
my side, which would last for several hours. These attacks de- 
veloped into such a derangement of the stomach that it would 
not retain food. The pain finally became constant, and I was 
seriously ill for about six weeks ; was confined to the bed, my 
back and head troubling me greatly. Prior to this, the worst 
pains in my back were between the shoulders, extending upwards 
to the head, and so severe as often to make me delirious for a 
few hours. 

In 1865, I had several abscesses, which were thought to have 
been caused by my having fallen down stairs. These abscesses 
are now believed to have formed in the left ovary. I had no 
more of them until about a year ago, but within a year have had 
several, all of which have been on the right instead of the left 
side. They have discharged through the vagina. 

I always had more or less headache during my " periods." For 
the last five years have had considerable pain in the small of my 
back, and in the womb itself. In the winter of 1867, I think it 
was, I was laid up for several weeks with lameness in the small 
of the back, could not move without help, and for some time there 
was no action of the bladder, the urine being retained. From 
that time until now I have suffered from scanty and irregular 
menstruation. The flow finally stopped entirely, and I suffered 
each month with pain, violent crampings, etc. 

I was married in 1860, at the age of 21 ; always menstruated 
properly until the time aforesaid, excepting about four months in 
the year 1859, when, for some unknown reason, my courses 
stopped. I did not, however, suffer much on account of it. My 
back always pains me somewhat, but when the different organs 
named are in a proper condition, I suffer no serious inconvenience 
from it. 

This statement shows, in very graphic outline, the chief points 
of interest in this case. But there are additional symptoms which 
our patient could not catalogue. 

For two years past, whenever the menses have been arrested, 
scanty, or tardy in their appearance, she has had 

Vicarious haematemesis. .. - "1 . 

vomiting of blood. This hsematemesis never 
comes excepting at the month, is not very copious, nor is it 



146 THE DISEASES OF WOMEN. 

accompanied or followed by any evidences of inflammation or 
of other organic disease of the stomach. 

She is also subject to periodical attacks of severe pain in the 

back and head, which end in spasms, delirium, and finally in 

clonic spasms of the muscles of the back, with 

Convulsions. . 

opisthotonos and fearful convulsions of all the 
voluntary muscles. Concerning these paroxysms, which are even 
more painful to her friends than to herself, the Doctor says ; 6 ' I 
have observed that the cramps, delirium, dilatation of the right 

pupil, pains in the spine, etc., invariably come 

The causes of. J 

on when there is any difficulty with the liver. 
The menstrual approach excites the same train of symptoms. So 
also does any mental trouble, disappointment, or other cause of 
serious mental excitement. 

" The sensitiveness of the spine is most marked in the lower cer- 
vical and upper dorsal regions. The spine, however, is somewhat 
sensitive throughout. She frequently falls to the 

Prodromata. . . 

floor ; but, when she has any premonition, usu- 
ally gets to a chair or lounge, and saves herself. These spells 
usually follow the more severe symptoms of spinal irritation. She 
has never been pregnant." 

The patient came to this city, and was under my care for sev- 
eral weeks. Her case was interesting and intricate, for several 
theories of her disease suggested themselves. 
Theories concerning the jj er iH nesss might be said to have dated from 

nature of the disease. ° 

her vaccination ; or to have been caused by the 
traumatic injury of the spine from the falling door, and from fall- 
ing down stairs (spinal irritation) ; to the hepatic complication ; 
the menstrual irregularity and suffering ; or to the epileptiform 
nature of the paroxysms. But the history of the case led us to 
infer that these causes had acted conjointly, or rather consecu- 
tively, to produce so complicated a set of symptoms. 

My friend, the Doctor, had faithfully applied the most appro- 
priate remedies for the relief of the individual and collective 
symptoms, but without any real or lasting bene- 
Fideiity in the use of f]j- # j n fafa treatment he had persisted for 

remedies. x 

more than two years. The menstrual derange- 
ment being marked and prominent, we concluded that it must be 
an important factor in the case. In his letter, the Doctor said : 



AMENORKHOEA — CONTINUED. 147 

44 The non-appearance of the menses and the scant flow have been 

invariably owing to the spasmodic closure of the uterine cervix. 

Whenever I have succeeded in passing a tent 

Cause of the menstrual w ithin the internal os uteri, the flow proceeded 

disorder. *- 

properly. But the introduction of that instru- 
ment was a proceeding in which I think there were more failures 
than successes. By the use of Atlee's dilator, however, I could 
accomplish the purpose with much greater certainty." 

Dilatation was therefore persevered with so as, if possible, to over- 
come the spasmodic closure of the cervix and to secure a free and 

easv flow of the menses. If this end were obtain- 

Failure of dilatation. *" . tit t 

ed, it was thought the result would be to bring 
relief to the nervous centers that were surcharged with blood — the 
patient being very fleshy and of full habit. But this means failed 
because of the persistent inclination to spasm of the uterine neck. 
For almost as soon as the tent, or Priestly* s dilator, had been re- 
moved, the cervix would shut so tightly that it would be next to 
impossible to pass the sound. 

We accordingly determined upon incision. The Doctor came 
to town and assisted me in the operation. I performed the bi- 
lateral section with a Simpson's hysterotome, 

of'the e c e?vix tionofincision but di( * not cut tlie wal1 of tlie cervix entirely 
through, as recommended by Sims, and prac- 
ticed by my friend Comstock. The hemorrhage, which was not 
severe, was arrested by a cervical tampon that had been saturated 
with the tincture of the per-chloride of iron. The patient was 
kept in bed for one week only, the cervix being dilated every al- 
ternate day with Priestly's dilator, to prevent atresia of its 
canal. 

She soon returned home, and with the occasional passage of the 

sound, and of the dilator (which are introduced without difficulty 

since the operation of incision), she menstru- 

Subsequent history. 

ates more regularly and copiously than she has 
done for a long time. Thus far she has had no more vomiting of 
blood. In other respects, also, her health is somewhat improved. 
The convulsive paroxysms are less frequent than they were. 
Their character and severity, however, are unchanged. The cer- 
vical and dorsal pains continue. The dilatation of the pupil and 
the temporary amaurosis are relatively infrequent of late, but 



148 THE DISEASES OF WOMEN. 

when they are present they have the same characters as before. 
This patient is therefore still und,er treatment. 

Now, gentlemen, I have brought this case to your notice for the 

sake of illustrating three very important points, viz. : (1.) That 

in your daily experience as practitioners, you 

Practical points. it ^ 

will discover that the diseases ot women are 
often more complicated than you had supposed they could be ; 
(2) that Uterine Surgery, and Uterine Therapeutics are by no 
means perfect and infallible ; and (3) that, in this as in some 
other departments of our art, rapid and brilliant cures are the 
exception and not the rule. 

If clinical teachers were always faithful to their trust, and if 

those who report their experience in our societies and journals 

always told the plain, unvarnished truth, such 

A fallacious idea. tip i i • i • i • 

cardinal facts need not be mentioned m this 
connection. But it is not so. Students are often led to believe 
that nosological distinctions are real, and that diseases run an 
uncomplicated and unvarying course. If they have little knowl- 
edge of human nature and of human frailties, and especially if 
they have seen but little of the " practice," they are decidedly 
impressed with this idea. But the illusion vanishes when they 
are brought face to face with disease. And I have sometimes 
thought that they are more likely to be undeceived in this respect 
in treating the diseases that are peculiar to women, than in their 
experience with any other class of ailments. This is a case in 
point. 

It is so eas}~ to dictate and dogmatize in these matters that one 
might prescribe a manual operation, or an internal remedy for 

such a patient, and insist that either of them 
m S?55T c surgery and should effect a cure. But you will find that 

these very complicated cases are not so easily 
disposed of. A certain operation, or a single remedy, may need 
to be modified or changed repeatedly, perhaps, before the 
cure is effected, if indeed it ever is. The incision of the cervix 
uteri in this case w x as of real service. It is a great point gained 
to have secured the regularity and freedom of the menstrual flow, 
and more than all, to have put a period to the hsematemesis before 
any manifest organic disease of the stomach had supervened. 
But the operation has not cured the woman at all. And it 



AMENORRHEA CONTINUED. 149 

would be wrong for me to report her as well again, when she 
is not. 

There are those who will tell you that this or that remedy, in a 

particular potency, would undoubtedly have cured her. But 

such an opinion is presumptuous. We can 

Do not claim too much. ... ttti 

accomplish much with our remedies. When 
fitly chosen they are wonderfully efficacious. Every year their 
curative scope is widened, and their clinical range more accu- 
rately defined. But, although we can accomplish more than our 
predecessors ever did, and with means that they deemed too insig- 
nificant to be of any practical use, we should not claim that our 
skill and success are unbounded. If we are unreasonably confi- 
dent we defeat our purpose and disgrace our calling. 

The health of woman is exposed to so many vicissitudes, and 

she is the victim of so many interior sources of mischief, that you 

will always do well to qualify your prognosis 

Qualify your promises. . _ . 

and your promises to cure her, even ol the 
simplest ailment. Especially should you forbear from engaging 
to restore her rapidly to a good state of health, in case of any 
disorder of menstruation or of the nervous 
system. I once heard a physician claim that a 
single dose of sepia had entirely cured one of his patients of a 
long-standing and serious dysmenorrhcea. It had cut short her 
■suffering and relieved her like magic. This last result we were 
prepared to credit ; but, when he went on to say that the pre- 
scription had been made only a fortnight before, and that the men- 
strual cycle had not yet returned, every experienced person pres- 
ent knew just what to think of the rapid and radical cure which, 
in all probability, had not been effected. 

AMENORRHEA IN ADVANCED PHTHISIS. 

Case. — Miss E., aged fifteen. The menses appeared at four- 
teen, returned at the proper time for the following two months, 
and have now been suspended for ten months. About three months 
after the suppression she had a severe attack of haemoptysis, which 
continued at intervals for three weeks. She has headache all the 
time and chills every morning, which begin about 9 o'clock a. m. 
and last until 12 m. These are followed by a slight fever. There 
is great thirst, even during the chills. She has a cough, which 
is worse in the morning, and her lungs are very sore. Her father 



150 THE DISEASES OF WOMEN. 

and mother died ol consumption. Bryonia 3, every two hours 
during the day, and calc. phos. (5, at night. 

April 28. She is not feeling much better, has chills every morn- 
ing, and drinks a great deal during the chill. Her throat is sore 
from coughing. She cannot lie in bed, but must get up and move 
about. Arsenicum 3 and Bryonia 3 alternately every three hours. 

May 4. No better; the chills continue. Her feet have bloated 
since her last visit, and she has profuse night-sweats, headache in 
the morning, and the fever lasts until night. The hectic flush is 
quite pronounced, and the pulse is 160. Lachnanthes 3, four times 
a day. 

May 11. She thinks she is feeling some better. Has had less 
headache and fewer chills, appetite is better, and she rests better. 
Her feet are still so cold that hot foot-baths are necessary several 
times during the day. Her pulse could not be counted. Lach- 
nanthes 3. 

(Exit the patient.) I have sent this poor girl to the waiting- 
room in order that you might hear my prognosis, and that 1 may tell 
her afterward the plain truth concerning the gravity of her symp- 
toms and our inability to do anything for her permanent cure. 
In such a case as this, which is really one of tuberculosis in its 
latest stage, the occurrence of the secondary amenorrhcea, like the 
sore throat, and dropsy of the feet and limbs, is of fatal signifi- 
cance. Her disease is positively incurable, and I shall direct that 
she be sent to her relatives in the country,for fresh air, good food* 
and home comforts, while she does live. 

The clinical relation of amenorrhoea to tuberculosis is not 
always clear and explicit, but there are certain rules which may 
help us to decide what that relation is in a given case. For ex- 
ample: If the primary lesion has developed within the thorax, 
the menstrual involvement may be late in making its appearance. 
This is the form of suppression that usually occurs in the last 
stages of "consumption." But if the original deposit is anywhere 
within the abdomen or the pelvis, in the peritoneum or the inter- 
nal generative organs, the interruption of the monthly flow will 
happen much earlier, or it may perhaps be the first and most 
prominent of the morbid symptoms. These facts square with the 
spread of the disease and the invasion of the adjacent organs,, 
everything depending upon the point of attack. 



Part Third. 



THE DISORDERS OF MENSTRUATION. 



LECTURE IX. 



MENSTRUAL HEADACHE. 



Menstrual Headache. Case.— Often overlooked— from uterine deviations. Case.— Ovula- 
tion and cephalalgia— diagnosis, prognosis and treatment. Case.— Menstrual retention 
cause of uterine displacements. 

Case. — Mrs. , aged 40, began to menstruate when she was 

only twelve years old. About that time she commenced to have 
periodical attacks of headache, which, she says, have always 
returned just before or just after the " courses." She is the 
mother of three children. With the exception of the time in 
which she was pregnant and while nursing her children, in each 
case, and also when, for some unknown reason, the menses were 
suppressed for twelve months at another time, she has never failed 
in twenty-eight years to have this headache every four weeks. 
The arrest of the catamenia took place two years ago, and afforded 
a complete immunity from these attacks. When the flow was first 
restored it was slightly irregular in its return, but the headache 
came on again, and since that time it has been more severe in 
degree than ever before. 

The pain is located in the temples, and across the frontal region, 
is aggravated by light, but not by noise. It occasionally, although 
very rarely, happens that a paroxysm is caused by over-fatigue and 
anxiety. During the attack she sometimes has slight nausea, there 
is occasional vomiting, weakness, a feeling of inability to stand or 
walk, and a very decided anorexia. She has consulted many phy- 
sicians, but without benefit. 

These few symptoms convey no very adequate idea of the suf- 
fering involved in the monthly martyrdom to which our patient 

has been subjected for more than a quarter of a 
qumtfy o S 3o°S. fre " century. The case is by no means a rare one. 

There are those who have had this painful affec- 
tion during their whole menstrual life. And, strange to say, it 
frequently happens that this particular variety of headache is 



152 THE DISEASES OF WOMEN. 

often improperly diagnosticated and treated. I have seen patients 
who have been under the professional care of a number of physi- 
cians for this complaint, and although the monthly periodicity of 
their symptoms was as marked as in the case before us, no refer- 
ence had been made to it at all. 

The especial significance of the different kinds of headache that 
are incident to the sexual diseases of women is not as thoroughly 
understood by the profession as it should be. I can not hope to 
remedy this defect in their special pathology, but I desire to offer 
a few practical hints that are founded upon clinical experience. 

Nearly, if not quite all, these forms of cephalalgia are of reflex 

origin. The only prominent exception to this rule occurs in case 

of the impairment of the quality of the blood, as 

Reflex headache. . . f ,,,.,. P ,, 

in chlorosis, chloro-ansemia, the debility follow- 
ing abortion, menorrhagia, uterine leucorrhcea, or too prolonged 
lactation. The "menstrual headache," as it is termed, is almost 
always dependent upon ovarian irritation or inflammation. Hence 
the relation of the paroxysm to the return of the menstrual cycle. 
It comes regularly each month. It may either anticipate, accom- 
pany, or follow the discharge. The pain is most frequently 
located in the crown of the head, or it may be in one or both 
temples, in the orbital region, or even in the back of the head. 
It may or may not be accompanied by the " clavus hystericus." 
In chronic cases, it is sometimes described as " crushing, as if 
there were great weight upon the vertex." This is an intractable 
and persistent symptom, especially in women who are passing 
through the climacteric period. More frequently, perhaps, the 
pain is said to be " burning" in character, and circumscribed in 
extent. 

It is quite common for women with this kind of headache to 
complain of " strange " sensations in the head, or of " forge tful- 

ness;" or they will tell you that "half the 

Peculiar symptoms. • i i i it 

time they do not know what tney ai-e about. 
Sometimes, during the paroxysm, they will threaten to " go 
crazy," and, nolens volens, may put the threat into temporary 
execution. This is the form of headache with which those who 
are subject to difficult and delayed menstruation are most afflicted. 
Those who are of the hysterical or the neuralgic diathesis are par- 
ticularly liable to it. When it occurs as a concomitant of uterine 



MEXSTKUAT. HEADACHE. 153 

ulceration, I think you may refer the lesion of the cervix and the 
headache to some primary disease in one or both of the ovaries. 

Attacks of headache which are incident to uterine displace- 
ments and to leucorrhoea, resemble what is vulgarly styled " sick 
headache." In this form of the disorder, the 

Headache from uterine 

displacement and leucor- paroxysms recur without regularity and with- 
out any special reference to menstruation. In 
those who are susceptible, over-fatigue, want of proper rest, or of 
food, or an excess of mental excitement, may induce it. Here the 
gastric function is prominently and principally implicated. Inci- 
dentally, the most curious symptoms may attend it. One of my 
private patients described the feeling in her head as "a sort of 
wriggling, as from the movement of long worms, such as are 
found in vinegar." It is not unusual for such persons to com- 
plain of a sensation " as if the head had been scalped, and the 
brain left exposed." 

I once knew a woman to be confined to her room for fifteen 
consecutive weeks with a spurious typhoid fever. In her case, 
this headache returned every fifteenth day with 
the regularity of an ague. Her description of 
the paroxysm led me to infer that there was a possible dislocation 
of the uterus, although it had never been suggested to my patient 
by her previous medical attendant. I found that the womb had 
settled down upon the perineum. As soon as it was restored, the 
periodical headache vanished and her fever did not return. If we 
except the expedient of setting fire to the house, nothing will 
place some of these patients upon their feet so speedily as to re- 
store the womb to its proper position, and to keep it there. 

There is a prevalent idea that the menstrual headache is caused 
by a spasm or obstruction of the uterine cervix, which has the 
effect to prevent a ready exit of the menstrual 
a( Cause of menstrual head- fl ow j n exceptional cases, this may be true; 
but the reverse is certainly the rule. If it were 
not so, labor, either in abortus or at term, and indeed, whatever 
would secure the free expansion of the cervix, would cure it radi- 
cally and entirely. But this woman's history disproves the theory 
of its being due, in her case at least, to a lesion or spasm of the 
neck of the womb. She has had three children, and now is worse 
than ever before. 



154 THE DISEASES OF AVOMEN. 

Here the direct relation of the headache to the function of ovu- 
lation is shown, not only by the regularity of its return at the 
month, but also by a complete exemption from 

Proof of connection be- . , . . , . 

tween ovulation and the it during gestation and lactation. In prea- 

cephalalgia. & ° . . ^ & 

nancy, and while nursing, menstruation is 
physiologically suspended. When this function was arrested the 
headache ceased, and when it was resumed the headache returned. 
The same was true of the period during which, for some unknown 
reason, she had ameiiorrhoea. The periodical afflux of blood to 
the generative organs, but more especially to the ovaries, and the 
nervous tension and erethism connected with the monthly crisis, 
appear to have been sufficient to cause the headache. As soon 
as the vascular and nervous energies were diverted and busy 
elsewhere, — in the developing uterus during gestation, and in 
the mammary glands while nursing her infant, — the remote 
cause was removed, and the effect ceased. 

This view of the etiology of u menstrual" headache is confirmed 
by the history of cases in which an incidental and temporary 
excitement of the generative system causes an 
wWcTs?mu1ate°rvuia'ti i on attack independently of, and without reference 
to the monthly return. There are those who 
always have it after coitus. In some it follows the first indul- 
gence of the sexual act after menstruation, or 

Exciting causes. 

prolonged continence. In others, a sexual or- 
gasm induced by emotional influences, especially if it is ungrati- 
fied, may be followed by a severe attack of this peculiar form of 
headache. Incompatibility in the marriage relation is a frequent 
cause of it. It is sometimes due to a temporary arrest of the flow 
for a few hours, or rather to what has been styled " intermittent" 
menstruation. Or it may depend upon too scanty or too copious 
a discharge. In brief, in certain women, whatever mental or 
physical causes are sufficient greatly to derange the circulation 
and innervation of the internal generative organs are capable of 
inducing the "menstrual headache." 

Suppose we interrogate this patient a little farther, and ascer- 
tain if there are not other symptoms with which we should become 
acquainted. 

" Are you quite well, madam, with the exception of the head- 
ache ? " " No, sir, not entirely ; but the pain in my head, when 



MENSTRUAL HEADACHE. 155 

» 

it does come on, is so much worse than anything else, that I make 
no account of the other symptoms." " What other symptoms 
have you?" " I have a feeling, sir, as if 'my limbs were gomg to 
sleep. It requires a great effort for me to keep about, and I am 
very sensitive to the cold air." "Do you have these symptoms 
now, midway between the periods?" "Yes, sir," k Tell me 
how you feel when the flow commences, and while it continues." 
"■I often have a kind of spasm in the bowels, which comes on just 
before the discharge begins, and then goes off again. Sometimes 
I become a little blind, and so long as I am sick there is more or 
less darkness before the eyes, so that I can not see distinctly." 
"Do these last symptoms disappear as soon as the flow stops?" 
" They do." " Show me where the pain is located/ " It is here, 
sir, in the left side, right over the hip. Sometimes it is in the 
groin, and shoots down that leg , at other times, saving your 
presence, it passes into my belly. And sometimes there is a 
throbbing in the lower part of my back-bone." "Are you quite 
certain that these symptoms return every time you are sick?" 
" I am, sir , they are as sure to come as the flow itself." 

Now, therefore, if there have been any doubts in your minds 
as to the interpretation of this case, I think they will have van- 
ished with the close of this examination. You 
kJon rch for the primary mav sometimes find it even more difficult to 
locate the original lesion which has given rise 
to a sympathetic headache, such as that of which our patient com- 
plains , but you should always search for it. For, depend upon 
it, although you may fail to remedy an obscure case, if you can 
explain its special pathology, its cause, course, nature, and prob- 
able termination, you will have almost as strong a hold upon the 
confidence of the patient and her friends as if you were realis- 
able to cure it. 

There is no especial difficulty in diagnosticating this from other 
varieties of headache. The "sick" headache affects males and 
females indiscriminately, and sometimes affects 
he?da?he? is-f '-' m ' ' sick quite young children also. It is not regularly 
paroxysmal. The fits have no especial relation 
to the menstrual cycle, but may be brought on at any time by an 
excess of anxiety, fatigue, or the eating of improper food. The 
paroxysm passes off with sleep, or is relieved by pressure, as from 
a handkerchief bound tightly about the head, and sometimes ends 
with emesis. The gastric function is chiefly deranged, and 






156 THE DISEASES OE WOMEN. 

nausea, retching, and vomiting almost always attend it. It may 
occur prior to puberty, and also after the climacteric. In many 
women the paroxysms of this headache are more frequent during 
the early months of pregnancy and lactation than at other times. 
Those who are subject to it are apt to be wretched and hypochon- 
driacal. It is sometimes cured by change of climate. 

The " neuralgic" headache is traceable to vicissitudes of 
weather, unusual exposure, especially to wet and cold, prolonged 

mental strain, insufficient nourishment, nervous 
ache° m " neuralgic " head " exhaustion and perturbation of the mental 

faculties. Unless of a regular intermediate 
type, as in orbital neuralgia, or " sun" headache, it does not recur 
regularly, and has no especial relation to the menstrual function. 
It is often relieved by eating or drinking. The rheumatic dia- 
thesis is a strong predisponent of this variety of headache. Seam- 
stresses and others who live upon a light and insufficient diet, 
who are underfed and overworked, and who drink much of tea 
and coffee, are very liable to it. It is sometimes caused by 
decayed teeth. The pain is piercing, darting, lancinating, and 
erratic, sometimes present in one part of the head or the face, and 
again in another, now superficial, then deep-seated. 

The " congestive" headache, of which one sees more in the 
medical books and journals than in actual practice, is marked by 

a flushed face, redness and suffusion of the con- 
headaSie U congestive ' junctivse, either dilated or contracted pupils, 

photophobia, an intolerance of noise, and a full 
pulse. This form of headache is usually a concomitant of some 
local inflammation, and subsides without any very serious con- 
sequences. 

The " hysterical" headache differs from those of which I have 
spoken, in the period of its occurrence and recurrence, in the 

fixed limit of its location, in the fitful flow of 
ache° m hysterical " head " animal spirits which accompanies it, and in the 

marked effect that the most trifling emotional 
influences have to increase the suffering. It is very likely to 
recur at the month, more especially if the patient has dysmenor- 
rhea, or spinal irritation, but is not by any means confined to that 
particular period. Some women always have it if the menses are 
delayed or suppressed. In other cases it is a sequel to menor- 






MENSTRUAL HEADACHE. 157 

rhagia. The paroxysm may be caused, and may come and go, in 
the same manner as the true hysterical fit. 

The proper " menstrual" headache returns with the regularity 
of an ague paroxysm every time the woman menstruates. If its 
habit has been to come on at the beginning of 
stra^headach? 116 ""^ tne mont hly crisis, this habit will be persevered 
in. If it has been accustomed to return at the 
last of the month, just as the flow has almost entirely ceased, you 
may expect it again at the same season. If your patient menstru- 
ates once in three weeks it will not fail ; if every six weeks she 
will not escape it. Nor does it matter if she has had an incidental 
attack during the inter-menstrual period. It will be all the same, 
whether sooner or later, whenever ovulation takes place. Preg- 
nancy, lactation, amenorrhoea, the climacteric, or whatever inter- 
rupts the menstrual function, will arrest it. When this function 
is restored, it will come again. The degree of suffering in the 
head is not always in ratio with the quantity of blood that is 
lost in menstruation, neither with the intra-pelvic pain and dis- 
tress that are experienced in getting rid of it. The quasi-hysteri- 
cal symptoms which sometimes attend upon attacks of this head- 
ache, are incidental merely, and not at all characteristic. In the 
majority of cases a close and careful examination reveals either 
sub-acute or chronic inflammation, irritation, or neuralgia of one 
or both of the ovaries. 

The prognosis will vary with the age, temperament, and sur- 
roundings of the patient, the nature and duration of the sexual 
disorder, the possibility of controlling and direct- 
ing her emotional states and the condition of 
her general health. Chronic cases are not so readily cured as 
those which are more recent, and therefore less complicated. The 
nearer the approach to the climacteric, the less promising the 
case. When the menses cease, however, the headache will prob- 
ably stop of its own accord. Frequent child-bearing, but more 
especially frequent abortions, render this disease more intractable 
than it is under opposite circumstances. Domestic infelicity is an 
almost insuperable obstacle to the cure of this form of headache. 
The periodical engorgement of the ovaries, which is contingent 
upon menstruation, lights up, renews, and perpetuates the lesion 
of those organs, whatever it may be. If we can prevent the 



158 THE DISEASES OF WOMEN. 

monthly exacerbation of the sexual disorder, and can so regulate 
this function that it shall become physiological and healthy, the 
cure is practically accomplished. Otherwise, the disease may 
continue and increase until the general health gives way and fatal 
results follow. In those who have what has been styled the 
"insane neurosis," or predisposition, it may finally develop into 
some form of insanity. 

Treatment. — The first indication is to correct and control all 

those circumstances and habits which cause an undue afflux of 

blood to the internal generative organs. The 

Hygienic treatment. . 

eating 01 improper or too highly seasoned tood, 
the drinking of wines and liquors, too much or too little of 
society, all those mental and moral influences that stimulate the 
sexual appetite, tight lacing, running the sewing machine, and 
constipation, are among the avoidable causes of this disease. 
Horseback riding has induced it, and might therefore be preju- 
dicial. Exceptional cases are greatly benefited by the prohibition 
of sexual congress for the space of a week- before the commence- 
ment, and a week after the cessation of the monthly flow. One 
of my patients insists that she is almost certain to suffer a severe 
attack of headache, if the act is performed in the early part of 
the night, when she is weary, instead of in the early morning 
when she has been refreshed by sleep. 

If there is a deviation of the uterus from its normal position, it 
should be replaced. If there is any obstacle to the free exit of 
the menses, whether in the form of atresia, or flexion, or of strict- 
ure of the uterine cervix, it should be removed. The general 
system should be fortified against all debilitating influences what- 
ever. In the intra-menstrual period she should be well nourished 
and sent to walk or drive in the fresh air and sunshine every day. 

Rest at the month is an important element of cure in menstrual 
headache. Neither the body nor the mind should be overtaxed at 
this period. You should be particular in this regard, else the 
patient may unwittingly upset all that you have done and can do 
for her relief. If she is occupied as a seamstress or school-teacher, 
nurse, clerk, housekeeper, or what not, she should, as far as pos- 
sible, avoid all excess of care, confinement and toll for a few days 
before, during, and immediately after the catamenia. If she 
belongs to the higher class, she should be advised to shun all 



MENSTRUAL HEADACHE. 159 

excitement, to forego her fashionable appointments in society, 
parties, balls, the church, the theatre, and the opera, whenever 
the crisis comes, and to take the best possible care of herself until 
it has passed. 

The extremities should be kept warm, the head cool, the skin 
soft and flexible, the urine free, the bowels regular, the circula- 
tion equable and uniform, more especially for some days before 
the flow is due. Such patients should be protected from exposure 
to stormy and cold weather. One of the worst possible things 
for them is to get the feet wet and chilled with snow-water. 

When this disease is engrafted upon a neuralgic diathesis, elec- 
tricity properly applied is sometimes very beneficial. In some 

cases relief may be obtained by having the spine 
m ^ C e*fem. yand and extremities thoroughly rubbed at stated 

intervals by one who is strong and healthy. I 
have known a few cases to be cured by an itinerant "magne- 
tizer." 

The remedies most serviceable in this disease are those which, 
oecause of their relation to the reproductive function, are most 

frequently indicated in menstrual derangements. 

Indeed, the symptoms that pertain to the lesion 
upon which this headache depends are often, although not always, 
a better guide to the choice of the remedy than the peculiar 
character of the headache itself. Pulsatilla, sepia, nux vomica, 
belladonna, ignatia, calcara carb., platina, baryta carb., lachesis, 
chamomilla, and apis mellifica are the chief representatives of this 
class of remedies. 

If you will compare this woman's symptoms with those proper 
to sepia you will recognize their marked similarity, and agree with 
me that she should take this in preference to any other medicine. 
In another week she will be " unwell," and during that short 
interval she had better take a dose of sepia every evening. Let 
her report at the end of a fortnight. 

One of our cleverest graduates, Dr. R. B. McCieary, has re- 
cently sent me the notes of a remarkable cure of this form of 
headache by the use of gelsemium. I will read them to you. 

Case. — Miss McD., aged twenty-six years, with dark hair and 
eyes, of a medium height, and dark complexion, has been troubled 






160 THE DISEASES OF WOMEN. 

with headache all over the head for about six years. Occasionally 
she has very severe attacks, which last for several days with 
great prostration. She has taken various old-school remedies, 
but without benefit. I was called during- one of her severe at- 
tacks, and found her almost frantic with the pain, very nervous, 
and complaining of being sore all over, as if she had been pounded 
or bruised. She also complained of a "peculiar sensation, as if 
the head were full of worms crawling through the brain." I 
gave her gelsemium 200, a dose every three hours, which cured 
her as if by magic, and there has been no return of the disease 
since, now about " six months." 



MENSTRUAL RETENTION A CAUSE OF UTERUNE DISPLACEMENTS. 

Dr. Rigby to the contrary notwithstanding, it is undoubtedly 
true that many examples of uterine displacement are referable to 
other causes than external violence, morbid growths, and the 
parturient act. Among these causes there is one which has been 
almost entirely overlooked. I allude to an habitual delay or 
retention of the menses. 

A patient has dysmenorrhea. As a condition of functional 
activity, the uterine tissues are surcharged with blood, which 
moves sluggishly through them. The uterine 
th^weightofThJwomb 356 mucous membrane has shed or secreted the 
menstrual product into its cavity ; but this 
product cannot pass through the internal os uteri and the canal 
of the cervix. In order to empty the womb of what should 
escape without suffering or delay, the reflex phenomena of labor 
are requisite. The increase in the blood-supply, the torpidity of 
its circulation, and the retention of the menses within the womb, 
add to its volume and weight so as to drag down and displace it. 

Whether the dysmenorrhcea be congestive, obstructive, ovarian, 
spasmodic, or membranous, the consequence is a stasis of blood, 
and incidental suffering and disease. The proper balance between 
supply and waste, whether as respects structural repair or secre- 
tory demand, is lost. Textural changes in the inferior segment 
of the womb and in the cervix are almost certain to follow. The 
infiltration of the tissue may result in induration, hypertrophy, 
neoplastic growths, or unnatural adhesions. 

In such a case the displacement is, perhaps, active and tempor- 
ary. It may alternate with almost perfect health, and return with 



MENSTRUAL RETENTION, ETC. 161 

each menstrual cycle, to be relieved by the flow. It is not 
unusuaL for patients to complain of symptoms 
mSdi placements at the tnat are ^ ue especially to prolapsus or ante ver- 
sion, whenever they menstruate. Many women 
learn from experience that much of the suffering incident to dys- 
menorrhcea may be relieved by raising the hips and lowering the 
head. One of my patients told me that for years she had derived 
more comfort at such times from placing her feet upon the high 
foot-board of her bed, and dropping the head very low, than 
from anything she had ever taken internally or used locally as a 
palliative. 

More frequently, however, and for reasons already specified, 
the luxation becomes chronic. The monthly period recurs so 
soon that the patient has not recovered from 
and^vhy^ 001116 chronic, one attack before another is precipitated upon 
her. It is like attempting to cure an acute 
gastritis while the patient continues to eat regularly and heartily 
of indigestible food. 

Nor is the mere increase of weight in the womb the sole cause 
of the uterine deviations which are incident to dysmenorrhcea. 
The more decided and powerful the expulsive 
utfrus Ulsive effort ° f the P ams (which are designed to force the flow), 
the greater the liability to displacement ; just 
as in labor at term the uterus descends in ratio with the strength 
and persistence of its contractile effort, and may even escape the 
vulva without first being delivered of its contents. And this is a 
veritable labor. There are the same contingents of structural 
change in the uterus, and of relative displacement of the organ, 
that attend upon abortion and full term delivery. The difference 
is one of degree, and not of kind. 

Amenorrhcea (suppressio mensium) sometimes results in uterine 

displacement. This is especially true of those cases in which 

certain kinds of exposure or exercise have 

Uterine displacements in • 

irom temporary suppres- arrested the now at the moment it was due. 

sion. 

If a woman sets out for a sea voyage, or a 

voyage by rail, the day before her menses should appear, she will 

be very apt to skip one period, and perhaps more. Or, if the 

flow comes, she may experience greater suffering than usual. If 

it be too scanty, or too profuse, she may be very ill. As an indi- 
11 



162 THE DISEASES OF WOMEN. 

rect consequence, she will be likely to suffer from some form of 
uterine flexion or dislocation. 

There is no question but that many cases of this kind are due 
to such slight and apparently trivial causes. It may be as harm- 
ful and injudicious for some women to leave 

Carelessness at the month. 1 . . 

home on the eve 01 menstruation as it would 
be for others to go to church or to a concert when in momentary 
expectation of childbirth. I have known a rough ride in the 
carriage or upon horseback, taken at this particular period, to 
cause a decided prolapse of the womb. And in the nature of 
things, there is no reason why it might not frequently happen. 
According to Wright, "a displacement of the uterus is just as 
much an absolute fact as the occurrence of a hernial protrusion," 
and hernia has certainly resulted from a similar cause. 

I do not wish to be understood as teaching that all, or even a 
majority of cases of uterine displacement are chargeable to men- 
strual obstruction or derangement. I only insist that this class 
of causes and their manifest consequences shall not be overlooked. 
The truth is that our writers and practitioners are accustomed 
to magnify the importance of hygiene as applied to gestation, 
while they make but little account of that proper to menstruation. 
In so far as uterine deviations are concerned, we are prone to 
discriminate loosely in favor of those sequelae which may follow 
the parturition of the embryo and foetus, and to discard all such 
as are consequent upon that of the menstrual product. 

Treatment. — If this view is correct, the inference is obvious. 

The cure of this kind of displacement must hinge upon the relief 

afforded to, and the regularity of, the men- 

The indication is to cure s trual process. If the dislocation, of whatever 

the menstrual disorder. J- 

variety, depends either upon dysmenorrhea, or 
simple retention of the menses, the first thing to be done is to 
remedy the catamenial disorder. To treat the case simply as a 
displacement, and to expect to cure it by any universal expedient 
whatever, whether local or internal, will be unsatisfactory and 
unsuccessful. Emmenagogues would only increase the difficulty.. 
And so also would astringents. The pessary would be of no 
more service in such a case than a hernial truss. Indeed, it might 
prove as harmful in a displacement arising from this cause as it 
has been beneficial in others. 



MENSTRUAL RETENTION, ETC. 163 

This theory explains the wonderful efficacy of some of our 

remedies, when prescribed for the relief of uterine luxations. 

Through their manifest and well known rela- 

Modusoperandi of some ^ on j- Q ^ menstrual function, we have learned 

remedies tor prolapsus, etc, ' 

to rely upon them for the cure of those dis- 
placements of the womb that are consequent upon certain 
derangements of that function. In other words the key to their 
curative range and adaptability is found in their power to remove 
the condition upon which the disorder of place depends. From 
the provings alone we might never have learned what we already 
know empirically, logically and physiologically, of the power 
of certain remedies indirectly to influence the position and rela- 
tions of this very important organ. 

There is an excellent and harmless auxiliary which can be used 
in some of these cases to great advantage. I allude to the sponge 

tent, which by removing the mechanical cause of 
fui T a h uxma ry Se tent a " se " tne retention, may relieve the difficulty and help 

to cure the displacement. I am not aware that 
others have recommended this instrument in any form of uterine 
luxation. But it is a temporary, non-medicinal, unobjectionable 
expedient, which can be employed without risk, and in such a 
manner as to secure the free exit of the menstrual fluid as soon 
as it is poured into the uterine cavity. It certainly does not inter- 
fere with the action of internal remedies, nor will it, if properly 
applied, give rise to anj T lesion of the cervix. It promotes the 
painless and gradual dilatation of the internal os, obviates suffer- 
ing, and averts the reflex symptoms of which the patient is so apt 
to complain. It does not lift the womb directly, but ministers to 
its reposition by unloading its vessels, so that it can retract. It 
should be introduced from twelve to twenty-four hours in advance 
of the menstrual period. At this time the internal os is " off- 
guard," and the operation is less painful and more successful. It 
should be allowed to remain in for from four to eight or ten hours 
according to circumstances. When it is removed, the patient 
should keep to the bed or sofa, and not be allowed to stand upon 
her feet for some hours, or even, perhaps, for days. 

It is a singular and significant fact that cases of dysmenorrhea 
which merge into menorrhagia are rarely followed by uterine devi- 
ations of any kind. It is only when the absolute loss of blood 



164 THE DISEASES OF WOMEN. 

causes extreme atony of all the utero-vaginal tissues that such a 
result is witnessed. 

UTERINE COLIC. 

Case. — Mrs. sent for me in haste, on account of her sud- 
den illness. She had reached home from a long journey, and in 
perfect health, only an hour before. After a general bath, she 
took a vaginal injection of cool water, and, almost immediately, 
felt a sharp, spasmodic pain in the region of the womb. This pain 
increased in severity, and, before my arrival, became almost insup- 
portable. It would remit, and then return with redoubled vio- 
lence. I found her pale, with a cool surface, an anxious, implor- 
ing expression of countenance, and a slight nausea. She was 
midway in the inter-menstrual period, and had not eaten anything 
unusual, or, indeed, anything whatever, for some hours. 

A clinical lecture without a practical lesson would resemble a 

sermon without a moral one. There is a point in this case which 

you should carry home with you. It is this, 

timeTinfurious . 110115 some " tnat tnere are certain conditions of the womb 
and other pelvic viscera in which the shock of 
an otherwise harmless injection thrown into the vagina may work 
mischief. Whatever determines the blood to these organs increases 
the risk of using such an expedient suddenly, and, as it were, 
without proper warning and delay. A woman has been at work 
with a sewing machine for some hours consecutively. Having 
finished her task, she takes a bath, and directly afterwards a vag- 
inal enema. Almost immediately she is seized with symptoms 
resembling those from which my patient suffered. Or a similar 
result may follow a ride on horseback, or in the carriage, a game 
of croquet, standing for an hour or two at an evening party, toe- 
long a walk, a protracted lesson at the piano, or, as in this case, a 
fatiguing journey, all of which acts predispose to irritable condi- 
tions of the uterus. Under these circumstances there is an exalted 
sensibility of the organ, and it may happen that a single injection 
of cool water brought into contact with it suddenly will act as an 
exciting cause of pain and disease. 

The same is true of cool or cold injections per vaginam before 
the menstrual flow has entirely ceased. And likewise also of sim- 
ilar injections taken immediately after coitus, with a view to pre- 
vent impregnation. At such periods the capillary system of the 



UTERINE COX.IC. 165 

whole generative intestine is surcharged with blood. If we wait 
a little, this physiological afflux is removed, the erection of the 
organs subsides, and the proper vascularity is restored. But if we 
shock the delicate structures in the manner of which I have 
spoken, we must expect that, sooner or later, they will become 
diseased in consequence. 

In uterine colic the pain usually intermits. Sometimes the par- 
oxysm returns with almost as much regularity as the after-pains 
which torment multiparas, and which it is said 
to resemble. Or it may remit and not leave en- 
tirely between the more aggravated periods. The suffering is 
referred directly to the uterine region, although it sometimes radi- 
ates into the sacrum, and again into one or both groins. It is 
characteristic of this pain that it may be in a measure and some- 
times entirely relieved by pressure. The attack commences and 
terminates abruptly, and is not preceded or accompanied by any 
particular constitutional symptoms, as chill or fever. There is 
more or less of tympanites, which develops very rapidly and dis- 
appears as suddenly. There is usually considerable intestinal flat- 
ulence, distension and pressure. This bloating of the abdomen 
has all the characteristics of hysterical tympanites. Nausea is a 
frequent symptom in severe cases. 

The attack may continue for a few minutes only, or may extend 

through some hours, or even days. If it depends, as it sometimes 

does, upon uterine displacement, it may not 

Duration of the attack. . i t/» • ' • i 

subside until the organ is restored, it it is due 

to the presence of coagula, or other foreign bo lies in utero, it will 

only cease with their expulsion. In this case the pains resemble 

cramps, are expulsive, and labor-like. 

Women who are subject to dysmenorrhea are likely to have a 

mild form of uterine colic upon slight provocation. Such persons 
may be seized with it while walking in the 

rh^a ident t0 dysmenor " street, and be obliged to sit clown or bend them- 
selves almost double for a few moments, until 

the paroxysm passes off. Or the pain may be so severe as to cause 

fainting and great alarm. 

Emotional causes often give rise to it in hysterical persons. With 
this class of patients a fit of ano'er or jealousy 

Incident to hysteria. - . 

may bring on the attack at almost any time. 
Or it may precede menstruation and worry the patient for some 



166 THE DISEASES OF WOMEN. 

hours or days in advance of the flow. Although usually amiable, 
she will become petulant, is disgusted with and distrustful of 

humanity in general, and of the male sex in 
uot Y precede menstrua - particular. Sometimes she is in a mellow or 

pathetic mood, or she has a fitful religious mel- 
ancholy, or, what is still worse, is possessed with the insane idea 
to work, to set her room to rights, and the plants, the birds, the 
books, the pictures, stoves, chairs and furniture must be squared 
up and cleaned up instanter. She must do an immense amount 
of work in a short time, and only in so doing can avoid this tor- 
menting species of colic and ill feeling in the uterine region. 
After which, when the flow sets in, she is exhausted, fitful, capri- 
cious, cross, tempestuous, drums on the piano by the hour, or 
writes explosive letters to her husband, or friends, and regulates 
everything with the utmost irregularity. 

Extraordinary fatigue of body or mind may induce it. Intel- 
lectual, cultivated women, are more prone to it than others. 

Seamstresses, young ladies in boarding-schools, 
Most frequent among in- actresses, and those whose minds are harassed 

tellectual women 7 

with family cares, or who are ^victims of the 
social fret and friction which wear out so many valuable lives* 
suffer much from this painful disorder. 

Not unfrequently it arises from incompatibility in the marriage 
relation. Circumstances which develop a loathing of the sexual 
act, are very apt to produce it. It may originate either from im- 
moderate indulgence, or from being deprived of accustomed inter- 
course. I have known it to be caused by drinking ice-water while 
menstruating. 

Uterine colic is also incident to the neuralgic diathesis. It may 

alternate, or be complicated with ovarian neuralgia, hysteralgia, 

and even with rheumatism of the womb. In 

In neuralgic subjects. n 

women who are thus predisposed, whatever 
causes an irritable state of the uterus may bring on an attack of 
the colic. This form of the disease is very apt to seize upon nerv- 
ous and delicate patients during the period of pregnancy. 

Treatment. — Proper hygienic precautions will doubtless sug- 
gest themselves to your minds. You should 
^Hygienic and prophyiac- warn the patient of the possible consequences 
of vaginal injections at improper times. And 
also of the ill effects of rude and violent exercise, whether of body 



UTERINE COLIC. 167 

or mind. If she is intelligent — and your merits will commend 
you to this class of patients especially — explain the modus oper- 
andi of those very common causes of disease and suffering among 
women. One good, logical reason will have better and more last- 
ing effect upon her than any amount of scolding and fault-finding. 
A good prophylactic is to have the patient wear an extra layer of 
flannel, silk, or cotton batting over the abdomen habitually. 

Various palliatives have been recommended to put an end to the 
paroxysm. Among the more ordinary and available of these is 
the application of towels or flannels that have 
been dipped in hot water, mustard water, hot 
brandy and water, and the like. In some cases, a sinapism will 
cause the pain to vanish in a very few minutes. Bags of hot salt, 
or of dry bran heated thoroughly, are especially useful in case of 
menstrual colic, and of uterine colic following abortion. In hys- 
terical subjects, the ether spray may be thrown upon the hypo- 
gastrium. In inveterate cases, the vapor of chloroform has been 
injected into the vagina. Dr. Simpson advised a similar applica- 
tion of carbonic acid gas. When complicated, as it sometimes is, 
with vaginismus, I am in the habit of prescribing a vaginal injec- 
tion consisting of chloroform one drachm, olive oil and glycerine 
each two ounces. Or the same may be applied by means of a cot- 
ton tampon. If the attack is incident to delayed menstruation, 
the warm sitz-bath may afford the desired relief. 

In the majority of cases, belladonna or atropine answers every 

purpose. This is especially true if the attack has been caused by 

the shock from vaginal injections taken at im- 

Internal remedies. . 

proper times. Ii the case is manifestly neu- 
ralgic, and more particularly if it is complicated with ovarialgia, 
the valerianate of zinc may be indicated. 

Other remedies are colocynth, ignatia, caulophyllin, cocculus, 
chamomilla, nux vomica, pulsatilla, sabina, and secale cornutum. 



LECTUEE X. 



MENSTRUAL EPILEPSY. 

Menstrual epilepsy.— Case— uterine and ovarian epilepsy—from amenorrhoea. Case— intra- 
menstrual epilepsy, do. after dysmenorrhcea, sequelas and non-sexual causes of, prog- 
nosis, treatment, -Irregular Menstruation with Epileptiform Hysteria. Case.— a com- 
pound affection. Case.— the two distinct and distinctive stages of the fit. Case,— 
diagnosis, prognosis, and treatment.— Too frequent Menstruation in Incipient Phthisis. 
Case.— menstruation and tuberculosis, monorrhagia and do., significance of the 
aphonia, treatment, remedies, season and climate, mental worry. 

This woman is an out-patient who has been prescribed for sev- 
eral times already, and whose case possesses some items of clinical 
interest. 

Case. — Mrs. W., aged forty, had, seven years ago, what seemed 
to be an attack of sunstroke, and soon after, a fall down stairs, 
since which time she has had much pressure in the back part of the 
head and down the neck. Her headache is accompanied with a 
flushed face and vomiting. She sometimes becomes blind, espe- 
cially in the left eye, and, when the pain is very severe, there is a 
spasmodic jerking of the eyelids. At other times she has shoot- 
ing pains in the eye-balls, running from before backwards. 

About once in three weeks, after suffering extremely with these 
headaches she falls into a fit, and becomes quite unconscious for a 
time, frothing* at the mouth and biting- her tongue. On coining 
out of the paroxysm she is wild, pulls her hair, and recovers very 
much exhausted. Then the menses appear, but the flow is scanty 
and intermittent. The abdomen becomes bloated, and she has a 
great deal of pain in the left ovarian region. She also has occa- 
sional colicky pains in the bowels, and a drawing pain in the left 
knee. Before the fits began she was regularly " unwell " every 
four weeks. Belladonna 3, to be repeated every three hours. 

One week later, she is doing well; continue the same medicine. 
She is quite certain that no one in her family ever had epilepsy. 

Third week. The menses have appeared, but she has had only 
one fit, and that less severe than usual, the flow being more free. 
She wakens at two o'clock every morning and cannot sleep any 
more. Nux vom. and bell., each one dose daily. 

Sixth week. She has had no more fits: the courses came on 
slightly for one day and then stopped, but returned the third day. 
Belladonna and hyoscyamus alternately. 

168 



MENSTRUAL EPILEPSY. 1(J9 

Eighth week. She is not so well, has had three fits, and was 
much prostrated by them. Examination with the speculum shows 
a large raspberry ulcer on the cervix uteri. Ehus tox. 3, every 
three hours, and glycerine and Hydrastis locally. 

Ninth week. She has been quite well until yesterday, when 
she had headache. Bell, morning and noon, and sulph. at night. 

Very few authors, and perhaps none which are accessible to 

you, have anything to say of Menstrual Epilepsy. Indeed, it is 

comparatively a rare affection, and years may elapse before you 

will see another marked case of this kind. The 

Uterine and ovarian . 7 . . . -, 7 , .-, 

epilepsy. epilepsia uterma and I epilepste ovarique are essen- 

tially the same, the disease being characterized 
by a return of the fit with the coming on of the menstrual period. 
The paroxysm is not at first purely epileptic, but epileptoid or 
epileptiform. It may finally develop into genuine epilepsy. 

There can be no question that certain diseases of the generative 
organs predispose to epilepsy. This is true of men and women 
alike. But the greater relative frequency of this disease among 
women is probably due to their peculiar nervous and sexual organ- 
ization. In them the slightest degree of irritation may be suffi- 
cient to cause this dreadful disease in one or another of its forms. 
With the return of the menstrual cycle it is not 

Pseudo- epilepsy. . . . -. e -. 

unusual lor women to experience a kind ol pseudo- 
epileptic seizure, which is self-limited, and passes off with the free 
establishment of the flow, or with its cessation. Some of these 
paroxysms are halt hysterical, and subside with explosive outbursts 
of crying, laughing or of copious diuresis. Or they may merge 
into a pseudo-narcotism which lasts for hours, or even for days. 

In other cases the convulsive attacks recur at the month with 
tolerable regularity, although the patient fails altogether to 

menstruate. This form of menstrual epilepsy, 

With amenorrhoea. . . , . . J , . . , , 1 . 

which is complicated with amenorrncea, is the 
most serious and difficult of cure. In fleshy women who are more 
than thirty or thirty-five years of age, epileptiform convulsions 
may co-existc with scanty menstruation, and increase in severity 
each month in proportion as the flow diminishes. Young women 
are also liable to this form of eclampsia as a contingent of too 
scanty menstruation. Maisonneuve records the following rare 
case of this kind:* 

* Recherches et observations sur l'epilepsie, Paris, 1863, 



170 THE DISEASES OF WOMEN. 

Case. — Rosalie M., aged 23, of a sanguineo- bilious temperament, 
a strong constitution, born in Paris, of healthy parents, was quite 
well until her eleventh year, when the premonitory symptoms of 
menstruation having appeared, she was seized with epileptic fits 
which could not be attributed to any other cause than the diffi- 
culty of establishing the flow. The discharge was irregular and 
deficient in quantity, and each return thereof was invariably pre- 
ceded or followed by the epileptic seizure, which returned only 
at this period, sometimes before, sometimes after it, whether in 
the day or at night, and never tailing excepting when the courses 
were very free. This state of things continued despite repeated 
bleeding, leeching, blistering, and the taking of anti-spasm odics. 
The paroxysms were preceded for some days by colic in the lower 
abdomen and an extreme lassitude. At the moment of the inva- 
sion the patient experiences a feeling of suffocation, then, two or 
three minutes later, falls, loses her consciousness, has severe con- 
vulsions of the trunk and extremities, and a red face, but no frothing 
at the mouth. 

It may happen, also, that epilepsy shall depend upon uterine or 

ovarian irritation, or upon both these causes 

mtra-meustruaiepi- combinecl and yet the attacks shall return 

lepsy. J 

only in the intra-menstrual period. Here the 
same rule holds as in those exceptional cases of dysmenorrhcea 
which are characterized by uterine spasms and suffering during the 
interval, and when the flow is not on. 

All causes, therefore, which are sufficient to derange the menstrual 
function may predispose to these epileptiform attacks. Of 109 epi- 
leptics, Beau found that in 43 cases the disease 
had commenced between the sixth and the twelfth 
year, 49 from the twelfth to the sixteenth year, and only 17 be- 
tween the sixteenth and twentieth year. In a special monograph 
on the subject, M. Marrotte concludes:* (1) That epilepsy is 
not nnfrequently caused by derangement of menstruation ; (2) 
that when it does not originate from these disorders, it may be 
aggravated by them; and (3) That epilepsy may sometimes be 
developed when the menstrual function is quite normal. 

Spasmodic and obstructive dysme nor rhoea are not unfrequently 
accompanied by convulsive symptoms, that finally take on the epi- 
leptiform character. The sudden arrest of the 

After dysmenorrhcea. n , „ . , . , , , , 

flow, as from fright, has been known to cause 
this form of epilepsy. It may also occur in consequence of uterine 

* Revue Medico-Chirugicale, Paris, 1851. 



MENSTRUAL EPILEPbY. 17.1 

deviations, more especially, it is said, in case of ante-flexion of 
the womb. The same is true of strictures of the cervical canal, 
whether from atresia thereof, or from its imperfect development, 
as in the " infantile" cervix. Other causes are emotional wear 
and worry, shock and alarm, hysteria, the indulgence of the de- 
pressing passions, masturbation, intemperance in eating and drink- 
ing, excess of mental labor and study, the climacteric contingen- 
cies, anaemia, chlorosis, rheumatic and neuralgic ovaritis, nympho- 
mania, the first or a forcible coitus, the repercussion of eruptions 
(especially about the head and neck), too prolonged lactation, and 
amenorrhcea. It may also arise from an insufficient development 
of the uterus, as in the case reported from Noeggerath's clinic* 

Case. — Margaret C, aged twenty-one years, native of Scotland, 
unmarried. Menstruation commenced at 15, and occurred three 
times at regular intervals of a month, then entirely disappeared, 
and remained absent nearly three years. Recommenced at 18, 
and continued a year with no nervous disturbance. Epileptic 
attacks then made their appearance at irregular intervals, com- 
mencing with muscular spasms in the right hand, the aura passing 
thence to the head. Nausea and intense cephalalgia continued 
more than an hour after the momentary attack. From the first the 
menses were exceedingly scanty, being a mere " show," with a 
great deal of dysmenorrhcea, continuing tut three days at the 
most. A moderately firm hymen closed the posterior two-thirds 
of the ostium vaginae. The uterus was a little more than the 
pre-puberal size, very movable, the cervix projecting into the 
vagina, and presenting the characteristic nipple shape. The sound 
entered the narrowed canal of the cervix with difficult}-, and showed 
the dimensions of the uterine cavity contracted in all its diame- 
ters. The most constant symptoms were cephalalgia of the right 
side, and shifting pains in the lumbar and right iliac region. 

To this list of causes must be added those which are common 
to the sexes, for women may also have epilepsy 

Non-sexual causes. . 

trom causes which are non-sexual in their char- 
acter. In the case before us the chain of morbid action seems to 
have been set in motion bv the sunstroke and the fall. Then came 
the headache, with pressure in the vertex and along the nape of 
the neck, the flushed face and the vomiting, and finally the falling 
fit, with unconsciousness and foaming at the mouth. And when 
one paroxysm had occurred there was the same tendency to a 

* The American Medical Times, June 4, 1864, papre 286. 



172 THE DISEASES OF WOMEN. 

repetition of it, as in case of any other periodical affection which 
involves the cerebro-spinal centres. 

This woman's epilepsy is evidently clue to the conjoined effect 
of the fall and the coup-cle-soleil, either of which causes might 
induce it in man or woman. But the peculiarity in her case is 
that for some reason the type of the disease is pronounced and 
unvarying. The fits return at the month and at no other time, a 
fact which makes them contingent upon menstruation. 

We are perhaps safe in saying that no woman ever had a serious 
disorder of the menstrual function without more or less derange- 
ment of the nervous system. In their clinical history, ovulation 
and hysteria are inseparable. The nervous erethism which is 
incident to the menstrual crisis is almost as cer- 

Epileptiform hysteria. . . . „ . n ... ., ,. 

tain, if not as necessary a condition thereof, as 
is the local determination of blood to the generative intestine. 
The frequent recurrence of this strain upon the nervous system 
predisposes this class of patients to all kinds of nervous diseases. 
And not only do slighter causes induce more serious consequences 
among them than with men, but the diseases which result from 
these common causes are in their case peculiar and often intract- 
able. They take their type from this periodical function, and, 
whatever their real cause or character, become confounded and 
complicated with its disorders. In such cases epilepsy and hysteria 
may co-exist and defy all differentiation. The menstrual derange- 
ment underlies the whole difficulty, but whether it stands in the 
relation of cause, effect, or coincidence, it may be impossible to 
determine. 

The fact that this patient did not inherit epilepsy, and also that 
the menstrual difficulty did not precede the 
coming on of these fits is very important. An 
analysis of the case which failed to take these items into account 
would be very unsatisfactory; and a plan of treatment which re- 
jected them and denied their significance would almost certainly 
fail. If epilepsy was hereditary the prognosis would hinge upon 
the curability of that disorder. If these epileptiform attacks 
were secondary upon dysmenorrhea, or other uterine lesions, 
whether original or acquired, the case would be very different. 

Traumatic injuries of the cerebro-spinal axis are comparatively 
more frequent and serious in women than in men. With them 



MENSTRUAL EPILEPSY. 173 

the slightest shock may upset and depolarize the nervous relations. 
The hysteroidal tendency not only increases the injurious effect of 
falls and blows upon the back and the head, but also complicates 
and perpetuates the difficulty. Hystero-epilepsy, hysterical paral- 
ysis and choreomania sometimes result from such accidents. The 
jar consequent on a fall upon either extremity of the spine may 
lay the foundation for protracted ill-health and complete physical 
disability. 

The sexual impressibility and excitability of which I have 
spoken are likely also to aggravate the effects of a severe conges- 
tion of the brain, as from sunstroke or any other cause. The 
remote consequences may be equally chronic and complicated. 
Indeed, in obscure cases of nervous disease among women, it is a 
good rule to inquire Avhether they have ever suffered from cerebral 
hyperemia, or from inflammation arising from this or from a similar 
cause. In my experience some of the most intractable cases date 
from an attack of cerebro-spinal meningitis, the chief remedy for. 
which is macrotin. 

Treatment. — This is one of those cases which the itinerant 
quack — and local ones, too, for that matter — -would promise to 
cure with a single prescription, and possibly with a single dose 
of medicine ! If I had brought this patient before you directly after 
the first recurrence of her period, and reported her as cured, simply 
because she felt a great deal better, and for once only had escaped 
the fits while the flow was on, I would have been guilty of a fraud 
upon each member of the class. If you had recorded this case in 
your note-books as cured, you would have written an untruth. 
And if it had been reported at that time in either of our medical 
societies or journals as a successful case, the profession would have 
been misled, and great mischief would have been wrought. 

Let me say, therefore, that no case of disease occurring in a 
woman, and implicating the menstrual function, 
either directly or indirectly, should be consid- 
ered as cured until at least three healthy "periods" have elapsed. 
And since this rule applies to a large proportion of the diseases 
which are peculiar to women, you should not only be chary of 
promising to cure them speedily, but likewise careful in claiming 
to have cured them at all. For in no other department of medi- 
cine are relapses so frequent and our therapeutic deductions so 
fallacious. 



174 1HE DISEASES OF WOMEN. 

In a case of this kind the first question to decide is, which of 
these several factors is most significant? Is it 

Query. 

the cerebral lesion, caused by the sunstroke; the 
fall and the concussion which she experienced; the scanty, inter- 
mittent, and more or less painful menstruation, or the " rasp- 
berry" ulceration, the effects of which require treatment? Or, 
can we relieve them all by the same means and simultaneously? 

This poor woman's health was so good before the accident, 
and even now is so slightly impaired during the inter-menstrual 
period, as to leave but little doubt that if she had escaped the fall 
and the effects of extreme solar heat, she would not have had this 
form of epilepsy. Therefore it seems most reasonable that we 
should treat her with reference to this fact. Moreover, if the 
lesion was caused in this way, its cardinal and essential symptoms 
must indicate the remedy or remedies. 

Belladonna seemed to take hold promptly, so that the patient 
and her friends, as well as our clinical assist- 
ants, thought she would get well very soon. It 
covered most of the symptoms, and was also indicated as an anti- 
dote to the special causes of which I have spoken. But its opera- 
tion in such a case can not be immediate, nor its effects thorough 
and permanent. We may need to give it again and again, and 
perhaps also to change the potency from the third to a higher one. 
The nux vomica was given for the relief of what has been im- 
properly styled "a characteristic" symptom — 

Nux vomica. x , , 1 . 1 r i 

I mean the early morning wakefulness. 
At the third prescription she took hyoscyamus, as a remedy for 
the intermittent menstruation. In cases in which 
the flow is scanty, fitful, spasmodic, and inter- 
mittent, you will often find that a few doses of hyoscyamus will 
relieve the difficulty. But if the cause of the trouble is mechan- 
ical, as from uterine deviations, or from cervical obstruction caused 
by polypi, fibroids and the like, it will fail, as all internal medica- 
tion must necessarily do. 

I ordered the rhus tox. chiefly because of the disclosure made 

by the uterine speculum. You can hardly go 

wrong in prescribing the internal employment 

of rhus toxicodendron in a case of genuine raspberry ulceration 

of the os-uteri. But you must be certain that your differential 



MENSTRUAL EPILEPSY. 175 

diagnosis of the ulcer is correct, or you may be disappointed with 
the result. I was once desired by a physician of my acquaintance 
to see a ' ; splendid case of raspberry ulcer of the cervix." A bi- 
valve speculum was introduced, the lips of the cervix uteri were 
separated, and what had been taken for a remarkable specimen 
of this particular form of ulceration, because of its color, I sup- 
pose, was the healthy, florid, intra-eervical mucous membrane. 

In this variety of ulcer the only topical application necessary 
may be composed of the rhus tox. or hydrastis tincture and gly- 
cerine. 

Mrs. is now taking belladonna 3, morning and noon, and 

one close of sulphur 6, every evening. She will continue this treat- 
ment until we hear from her again. {Exit the patient.) 

Some cases of menstrual epilepsy depend upon ovarian irrita- 
tion and inflammation. When this occurs in married women 
especially, the same remedies may be required as in a case of idio- 
pathic ovaritis, ovarian irritation, or neuralgia. Under these 
circumstances belladonna, colocynth, platina, lilium tig., alumina, 
calcarea carb., lachesis, mercurius sol., phosphorus, the valerinate 
of zinc, or some kindred remedy may be called for. In young 
girls and widows, marriage is exceptionally curative. Tissot cites 
a remarkable case of this kind : 

" I was consulted, three years ago, by a young man concerning 
the condition of his betrothed, who being otherwise in good health, 
was subject at the menstrual return, the flow being scant}', to vio- 
lent colic, which almost always threw her into convulsions. For 
three several times these fits had been epileptic. I ventured to 
promise him that, so far from aggravating her disease, marriage 
would probably benefit it, and the result justified my opinion. 
Her first confinement caused the menstrual colic to disappear, and 
consequently the epilepsy also. 

IRREGULAR MENSTRUATION WITH EPILEPTIFORM HYSTERIA. 

Case. — Mrs. , ag-ed forty-nine years, has been ill for more 

than thirty years. She was married when she was eighteen years 
old, and declares that she has not been well since that time. She 
says that her husband treated her very roughly from the first, and 
that in consequence the menstrual function became very painful 
and irregular. Within a fortnight she began to have a kind ol 
nervous fits or convulsions, to which she has ever since been sub- 
ject. These paroxysms have shown a marked tendency to recur 



176 THE DISEASES OF WOMEN. 

at the period, but occasionally, more especially when the menstrual 
interval has been prolonged, they have been more frequent. Asa 
rule, they anticipate the flow by one or two days; sometimes they 
come on after it has begun, and again they follow it. She insists 
that for thirty years she has never passed through a period without 
one or more of them. 

There is no perceptible aura in advance of the lit, but she has a 
decided disposition to sleep, and often passes into the paroxysm 
while sleeping, whether it be during the day or the night. She 
becomes totally unconscious, and is oblivious to all that has passed 
during the lit. The only way by which she knows that she has 
had one is by finding that she has bitten her tongue or lips, or 
being told of it by those around her. She froths at the mouth, 
and, it she happens to be standing, falls to the floor in an insensible 
state. The harder the paroxysm, the more decided the discolora- 
tion of the face, the stertor, and the disposition to sleep after- 
wards. The lighter the fit the more restless and nervous she is, 
with jerkings and twitchings, and spasms of the voluntary muscles, 
and a copious flow of urine at the close of the paroxysm. 

She has never had any children, nor has she ever conceived. For 
a year past the " change of life " has caused the menses to be even 
more irregular than heretofore. At one time she passed three 
months without any flow, during which interval she was exempt 
from the fits. But, when the catamenia returned, although they 
were not more profuse or painful than usual, she had three of 
these paroxysms in rapid succession. She is not very much more 
nervous than most women of her age, and although her memory 
is somewhat impaired, her faculties are not badly shattered. She 
is very religious, and has always attended church very regularly, 
and yet, during all this time, she has never had but one paroxysm 
during the service. 

At intervals for more than three years, this poor woman has 
been coming to our clinic and some of you have seen her before. 
She is a martyr to the kind of abuse of which there are many vari- 
eties, and to which there are but too many victims. For, in all 
human probability, if she had been properly treated by her husband 
in her early married life, she would have escaped the frightful dis- 
ease from which she has suffered for so many years, and from 
which she can only be relieved by the " change of life," or by the 
of rave. 

Epileptiform hysteria, or hystero-epilepsy, as it is sometimes 
called, is really a compound of hysteria and 

A compound affection. ., T . ' . ™ . , ., ■ 

epilepsy. It is a curious anection, and one that 
has recently attracted the special attention of neurologists. Au- 



MENSTRUAL EPILEPSY. 177 

thorities are not agreed as to which of these two disorders lies at 
the foundation of the difficulty, Charcot holds that hysteria is 
the essential disease, and uses the word epileptiform as an adjec- 
tive to qualify one variety of it. It is certain that in this mixed 
disorder these two affections may run a separate course, may 
mero^e or may co-exist with varying- decrees of intensity. For, 

O ^ ^ CD CD 1/ 

in one case the epileptiform quality of the fit may predominate, 
while in another its hysterical character will be the most promi- 
nent. 

Landouzy reports the case of a young woman who, having had 
epilepsy from her infancy, concealed the fact and 
was married in her eighteenth year. When it 
became known that she was subject to this frightful disease, it 
caused a great deal of trouble in the family, and she became hys- 
terical also. The paroxysms of both diseases came together, but 
nevertheless were distinct from each other. Her pregnancy and 
the birth of her first child reconciled the husband and wife, after 
which the hysteria disappeared, but the epilepsy remained. 

In epileptiform hysteria the prodroma, when there are any, 
and the first stage of the paroxysm, will reveal 

First stage of the fit. ., • ... ft , l rp / 

its epileptiform character. I he symptoms ot 
epilepsy always open the scene, and those of hysteria always fol- 
low in the order of sequence. This patient becomes pale at first 
and falls if she happens to be standing, or goes into the fit while 
sleeping soundly, the face thus becomes distorted and congested 
and she froths at the mouth, bites her tongue, is utterly oblivious 
to what is passing around her, and the muscles of the extremities 
are in a state of tonic contraction. These are evident symptoms 
of the epileptic seizure, and in her case they always accompany 
the first stage of the paroxysm. 

If she had epilepsy in an uncomplicated form, the fit would end 

with these symptoms. But in epileptiform hys- 

Second stage of the fit. . ,v l v <, +1 > / i 

teria, as the song has it, " there s more to fol- 
low." Directly the tonic spasms have yielded, a series of clonic 
spasms and slight convulsions come on; and, in a little while, 
the emotional symptoms of hysteria disclose themselves. Instead 
of stupor and indifference there is excitement and uproar, and the 
double paroxysm ends like a fit of common hysteria. 

Without extending my remarks upon this subject, I ought to 



178 THE DISEASES OF WOMEN. 

tell you that there are two or three methods of recognizing the 
severity of the epileptic complicatio.11, and the 
to 1 ^ r s edomiDating s y m P" consequent danger from this peculiar disease. 
In the first place the more pronounced the epi- 
leptiform quality of the affection, especially if the fits are fre- 
quent, the higher the range ot the patient's temperature; andjoer 
contra, the more decided the hysterical development, the slighter 
the variation of her temperature. In the second place, if the disease 
has continued for any considerable time, the mind will become 
dull and shattered in proportion with the predominance of the 
epileptic symptoms, and more acute and excitable if the disorder 
is chiefly hysterical. Thirdly, in the former condition the more 
frequent the paroxysm the greater the danger; in the latter, the 
patient may have a great many of them without increasing the 
risk. Charcot reports the case of a woman who 
had nearly two hundred of these fits in twelve 
hours without any serious consequences. Fourthly, if the hys- 
terical affection is most prominent the paroxysm may always be 
relieved by pressure upon the ovary, as directed for the simple 
hysterical fit. 

In the absence of an hereditary tendency to epilepsy, and in 
view of the fact that, in all these years the epi- 
leptiform quality of the attacks from which our 
patient has suffered has not broken down her nervous system, and 
ruined her mentally, we conclude that her disease has been chiefly 
of the hysterical order. The mode of its origin, and the men- 
strual complication also confirm this view of the case. 

These, indeed, were the considerations which led me to tell the 
class long ago that a favorable result might be 
looked for with the termination of her men- 
strual life. If the epilepsy had been more pronounced, I would 
not have promised such a result. You should not forget that 
complicated cases of this kind may expire by limitation at the 
climacteric. 

There is a mild grade of cases in which, under careful manage- 
ment, this affection may be more readily and promptly disposed 
of. But, in forming an opinion in a given case, due allowance 
must be made for the degree of the epileptiform complication, 
the possibility of its having been inherited, the curability of the 



TOO FREQUENT MENSTRUATION, ETC. 179 

local or functional lesion upon which the whole difficulty has 
been engrafted, and the duration of the disease. 

The negative results of treatment in this case should not, 
therefore, discourage you, or lead you to decide 
that this is necessarily an incurable complaint. 
Lachesis, belladonna, hyoscyamus, gelsemium, and a few other 
remedies given under appropriate indications, have done this 
woman some temporary good ; but they have had no lasting or 
permanent effect. 

For the present I will dismiss the case with the remark that, 
since this curious affection is compounded of 
t Jns e for dinal indiCa " hysteria and epilepsy in varying proportions , 
and since these two nervous affections are 
always symptomatic of some uterine or ovarian disorder, a 
rational and successful treatment must be based on the indica- 
tions that are furnished by these three factors. 

TOO FREQUENT MENSTRUATION IN INCIPIENT PHTHISIS. 

Case. — Mrs. S., aged 32, residing in an adjacent state, gives 
the following history of her case. She has three children, the 
youngest of which is four years old. She nursed the latter for a 
period of twenty months, her menses appearing but twice mean- 
while. For two years past she has menstruated as often as once 
in three weeks, and sometimes every two weeks. Originally, 
menstruation was regular, and normal in all respects. With a 
single exception, which occurred about four months ago, the 
menses have not been very profuse. Eight months ago she lost 
her voice, and in all this interval has not been able to speak aloud. 
She has no habitual cough or sore throat, but is subject to occa- 
sional attacks of diarrhoea, which is very debilitating, and some- 
times quite intractable. Has never had the aphonia before, 
neither was she subject to the croup, or to any anginose affection 
during infancy and childhood; is losing flesh rapidly; appetite 
capricious; perspires freely whenever she sleeps; no thirst; 
pulse one hundred and ten. Tuberculosis is hereditary in the 
family. 

The relation of the menstrual function to the development of 

hereditary tuberculosis is more significant than you may have 

supposed. The interval between puberty and 

tubercSs i0nand the a £ e of thirt y° r thirty-five represents the 

period at which females are most liable to be 

seized with symptoms of that formidable disease. After this 



180 



THE DISEASES OF WOMEN. 



period if the menses are regular, they generally escape until the 
great climacteric is passed. The first ten years of menstrual life 
show the largest proportion of cases and the highest rate of mor- 
tality from phthisis pulmonalis. It is not uncommon for this 
disease to appear in young girls at the time the catamenial func- 
tion is established. Retention of the menses is very often a pre- 
monitory symptom. We shall, doubtless, have occasion to confirm 
its clinical import. 

But it sometimes happens, that too frequent menstruation may 
take the place of an arrest or tardy appearance of this flow, in 
incipient phthisis. The case before us is one of this kind. For 
fifteen years, or from the age of fifteen to thirty, this poor woman 
menstruated regularly. Lactation was prolonged to twenty 
months, the menses appearing only twice before her babe was 
weaned. For the four months following, everything was normal 
in this respect. The courses then became too frequent, and have 
so continued until the present time. 

Healthy menstruation depends upon ovulation — the ripening 
and discharge of the ovum, which takes place every lunar month. 
It is possible that the physiological condition 
tubeTc°uTo h sif iaaad of this P ec uliar flow may be supplied in excep- 
tional cases of too frequent menstruation. But 
in young subjects, especially, clinical experience leads us to refer 
this remittent type of menstruation, as it has been styled by Dr. 
Tilt, to some severe constitutional or local disease or dyscrasia. 
Sometimes it is caused by uterine ulceration, which may be either 
benign or malignant. More frequently it is not organic, but origi- 
nates in the depraved and debilitated conditions of the system 
that are incident to phthisis pulmonalis, and to chronic diseases 
of various kinds. When it occurs so frequently, it loses the 
character of the catamenia proper, and becomes a passive haemor- 
rage. Under these circumstances the condition of the blood is 
such that it very readily escapes from the uterine mucous mem- 
brane, which is more than ordinarily congested. Whatever im- 
pairs the quality of the blood, may thus directly give rise to a too 
copious, as well as too frequently recurring menstrual flow. 
Hence it is, that instead of amenorrhoea in the early stage of 
phthsis, Ave sometimes meet with cases of troublesome and even 
dangerous menorrhagia. Indeed my own experience leads me to 



TOO FREQUENT MENSTRUATION, ETC. 181 

conclude that uterine haemorrhage, active or passive, is more fre- 
quent in women under thirty-live years of age, and who are pre- 
disposed to tuberculosis, than our authors and practitioners have 
generally imagined. As a rule, however, it is more liable to occur 
in advanced stages of the disease than in its incipiency, and in 
child-bearing- women than in those who are either unmarried or 
sterile. 

In either sex indiscriminately it is not unusual for phthisis to 
commence with laryngitis, and consequent aphonia. But the 
marked sympathy existing between the womb, 
aphSa. CanCe ° ftlie the ovaries, and the larynx, renders this com- 
plication more frequent among females than 
with males. The loss of voice in this case is significant and seri- 
ous. If it were hysterical, it would not have persisted so many 
months. In aphonia from spinal irritation, (unless it be trau- 
matic), the attack comes on abruptly, continues for a few days or 
a week at most, and is very apt to leave as it came. Emotional 
causes, menstrual or sexual excitement, or bodily fatigue, may 
induce either of these varieties of aphonia. The loss of voice that 
sometimes precedes an apoplectic fit depends upon congestion 
of the medulla oblongata about the ganglion of the pneumogastric 
nerve, and is a very different affair. The obstinate aphonia, the 
habitual diarrhoea, the menstrual irregularity, and the frequent 
pulse of this patient, are objective signs, which must be interpreted 
as premonitory of pulmonary tuberculosis. 

Treatment. — The remedy for this case is calcarea phosphorica ; 
and you will be surprised to observe how promptly and efficiently 
it sometimes acts under similar conditions to those presented by 
this patient. It may be given in the third, the sixth, or if you 
please, a higher potency. My own preference is for the third 
decimal trituration, of which this woman Avill take two grains 
three times daily. 

Not unfrequently the bichromate of potassa, phosphorus, 
sodium, or spongia, will relieve the hoarseness which is incident 
to these cases of incipient phthisis. For this purpose they may be 
given incidentally, or if otherwise indicated, in lieu of the calcarea 
phosphorica. 

It is quite as important to prescribe the proper hygienic condi- 
tions suited to this infirmity as it is to determine the choice of the 



182 THE DISEASES OF WOMEN. 

remedy. First and foremost this patient should, if possible, 

remove to a climate which is less humid than this upon the lake 

shore. This expedient is especially advisable at this season 

(February). For the weather of the late win- 

Season and climate. , , . , . , . ..... 

ter and early spring months in this vicinity is 
too changeable, and withal too damp, for persons who are predis- 
posed to laryngeal and pulmonary difficulties. 

She should, moreover, have a good diet, and plenty of fresh air, 
without fatigue. And what is still more important, she should 

avoid an excess of family care and worry. Any 

little fret or friction of the domestic machinery 
has a wonderful influence in keeping this class of patients always 
on the doctor's hands. 

Whether it be primary or secondary genital phthisis is of the 

chronic form, chronique d'emblee. It is particu- 
Genitai Phthisis. larly incident to puberty and the climacteric- 

The seat of the deposit varies, the peritoneum 
being most frequently attacked, and after it the Fallopian tubes, 
the ovaries and the uterus in the order named. The neck of the 
womb and the vagina are sometimes, but rarely, the seat of this 
disease. Tubal tuberculosis is intimately connected with the 
clinical history of salpingitis. If the lesion is limited to the tubes 
and they are removed as in Tait's operation, the local mischief 
must cease for a time at least. How soon, and how certainly, and 
in what form it will be likely to return must be decided by the 
subsequent history of these cases. The careful record of all cases 
upon which the extirpation of the tubes and the ovaries has been 
practised would furnish a valuable contribution to the clinical his- 
tory of genital phthisis. 



LECTURE XI. 

DYSMENORRHEA. 

Dys me no rrhaia — Definition and varieties— Obstructive Dysmenorrhea. Case. — causes, 
symptoms, complications, sequelae, diagnosis, prognosis and surgical treatment. Ob- 
structive dysmenorrhea from post-puerperal atresia. Case.— dates lrom puerperaiity.— 
(he result of adhesive inflammation and stenosis, a clinical lesson, a contra-indica- 
tionfor anaesthetics, the use of the uterine stem. 

Most women suffer considerably during menstruation. The 
kind and degree of pain experienced at the month, however, 
varies greatly within the limits of health, and with the ability ot 
the subject thereof, to bear it uncomplainingly. It is only when 
the pain is sufficient to make her ill, and to disable her, or to 
send her to bed, that we say of a woman that she has dysmenor- 
rhcea. But this form of menstrual disorder is not only painful ; 
it is also tardy, slow, scanty and irregular, and the discharge 
which is more or less changed in character, escapes with great 
difficulty. 

Authors have described several varieties of dysmenorrhea, but 
I prefer to classify them all under the three general heads of (1.) 
Obstructive, (2.) Neuralgic, and (3.) Membranous. There are 
examples of each of these varieties in our clinic to which your 
attention will now be called. 

1. OBSTRUCTIVE DYSMENORRHEA. 

One of my most intelligent and amiable patients has written 
the following history of her case, which for the sake of the bene- 
fit that may accrue to others, she has consented that I may read to 
you: 

Case. — I hardly know if I was a healthy child, but I was active, 
impulsive and sensitive. At eleven years of age the menses ap- 
peared, the result, perhaps, of the grief and excitement caused by 
my mother's death. For about one year they returned regularly, 
with little pain, and then ceased, owing, I think, to wetting my 
feet, and improper exercise. The result was a cough, dyspepsia, 
and other bad svmptoms. My father emploved a physician for 

183 



US4 THE DISEASES OF WOMEN. 

me, who, after several months of medical treatment, brought on 
the menses again, but with much pain. 

At seventeen years of age I was married, after which I resided 
four years in Boston. During these years, in which I experienced 
great mental suffering also, I suffered each month, resorting to 
such remedies as were prescribed in a domestic way by my friends 
such, for example, as gin, injections of laudanum, chloroform, 
ete. About this time I was seized with "vomiting attacks," ii- 
which I would vomit a tablespoonful or more of clear green bile 
every ten or fifteen minutes for twelve hours, but never for a less 
time. As the vomiting, sometimes with purging, continued, the 
pain would lessen and finally disappear. The nausea and retch- 
ing would leave suddenly and without apparent cause, for no 
medicine could be kept on the stomach long enough to produce 
any effect. These attacks returned at intervals of three, five and 
eight months. I was treated for them, by physicians in Elmira, 
N. Y., Boston, St. Louis, and Chicago, and no one Avas able to 
relieve me, or to decide upon the cause of these paroxysms. 

During the latter half of this period of ten years, my general 
health was much impaired, and I suffered greatly from gastric 
irritability and distress. From this irritation I have never found 
permanent relief. 

After four years residence in Boston I came to Illinois, seeking 
no particular medical aid for some years. At length I was in- 
duced to try a water-cure in New-York, where I had the first 
vaginal examination. As a result, I was said to be suffering from 
"an irritation of the uterus and vagina, and nothing more." 1 
remained three months under treatment, but still continued to 
suffer during menstruation. 

A few years later I was placed under the care of a noted speci- 
alist in this city, who toll me there was an "enlargement and 
retroversion" of my womb. He applied the caustic treatment 
for six months, and, although he declared that I " was cured" still 
I suffered as before, at each menstrual period. 

One year after this I went to another Hygienio Institution in 
New York. Here I was told that the " uterus was enlarged, in- 
durated, retroverted, and fastened down, and had entirely changed 
its structure, and that the change must have been going on for 
many years. After having been pronounced "cured" only one 
year before, this was rather discouraging news. I remained at 
this institution four months, whence I was discharged, not as cured, 
but better. Still I suffered with menstruation. 

In the winter of 1870, severe pain preceded the flow for several 
hours, and in addition to symptoms threatening a return of all my 
former clinic ulties . my bladder was much affected. At this time, 
and after a careful examination of my case, Dr. Ludlam decided 
the seat ot my difficulty to be " in the neck of the uterus," which 



DYSMEXOliUHCEA. 185 

he found was " almost entirely closed." Under his treatment I 
experienced almost immediate relief, my general health improved, 
the bladder trouble disappeared, the gastric disorder became less 
annoying, and I suffered little or no pain during menstruation. 
Six months have now elapsed since I have finished his treatment, 
and the cure seems permanent. 

Perhaps I should add that my pain was mostly in the abdomen, 
and of the nature of colic. Warm applications often produced 
fainting fits and always had a tendency of that kind. Looseness 
of the bowels frequently accompanied the pains. I could only eat 
a, very small amount of the simplest food. Eating always increased 
the pain. Finally, after nearly thirty years of painful menstrua- 
tion, I have at last found relief ! 

There is one point of interest in this case that is worthy ol 
remark. It is that, the form of painful menstruation from which 
our patient suffered was the natural sequence of her nervous con- 
stitution. Being sensitive, impulsive and active, she almost 
necessarily began to menstruate at an early age; and, when the 
function was established, it could not continue to be regular and 
normal as it might have done under different circumstances. In 
young girls of this temperament it often happens that menstrual 
disorders are attributed to getting the feet wet, and other acci- 
dents, when the real cause of the mischief lies in the too suscep- 
tible nerve centres. Her early marriage, the anticipatory vomiti ng, 
the sudden relief of the nausea, the abdominal colic, and the diar- 
rhoea, all resulted from the same nervous cause, or predisposition. 

Although the indications for treatment drawn from the study 
of the patient's temperament, are apt to be overated, I am in- 
clined to rely upon them in cases of this kind. And I advise you 
to cultivate the habit of looking for this nervous constitution, 
because it is a significant element in various menstrual disorders. 
This peculiar characteristic is plainly observable even in the style 
of her communication, and if this report had first come to me in 
the form- of a letter, I think it would not have been difficult to 
have read her temperament " between the lines." 

Obstructive Dysmenorrhoea is a variety of painful menstruation 

winch depends upon a partial or complete closure or obstruction 

of the canal of the uterine cervix, whereby the 

menstrual flow can only escape, if at all, with 

great suffering and more or less irregularity. Although it is by no 

means a rare affection, the history of this ease proves that it may 



186 THE DISEASES OF WOMEN. 

exist for months or years without being recognized and properly 
treated. 

The causes of this disease are various. Sometimes it depends 
upon the original conformation of the uterus and uterine neck, in 
which case, from the very first the " periods," are 
always characterized by unusual delay and suf- 
fering. More frequently, however, it is acquired at a later stage 
of menstrual life. It may result from a flexure of the womb, in 
which that organ is bent upon itself like a retort. Opposite the 
lesser curve, in this case, the cavity of the cervix is obliterated. 
Versions, prolapsus, and other deviations 

From uterine deviations. ' . . 

in the position 01 the uterus are less- 
likely to cause this form of dysmenorrhcea than flexions. And 
retro-flexion is more frequent in every form of painful menstrua- 
tion than ante-flexion. 

In certain cases the cervico-uterine orifice and canal are 
mechanically obstructed by the presence of a foreign body, sach 

as a polypus, a sub-mucous fibroid, or an old 

From intra-uterine growths. . " "_ 

coagulum, and, notwithstanding the most vio- 
lent efforts to expel the flow, it is partially or wholly retained 
within the womb. For this reason retention of the menses is 
often described by writers under the head of dysmenorrhcea, and 
vice versa. 

But a more frequent cause of obstructive dysmenorrhcea is a 
form of endo-cervicitis, in which the epithelial lining of the canal 

is exfoliated and lost, and, as a consequence 

From cervical atresia. 

adhesions are lormed between the opposite 
sides of the canal. These adhesions, whether traumatic, post- 
partum, or the result of a popular form of malpractice, that is of 
cauterization, cause an atresia which obstructs and practically 
closes the passage. 

As a rule, those women who have borne children, whether 
prematurely or at term, are supposed to be exempt from dysmen- 
orrhcea. But this form of the disease is b}^ no means a rare 
sequel to the abrasions and injuries consequent upon labor, as well 
as to the local inflammations which may occur about and within 
the cervix and the vagina during the puerperal state. 

The harsh and indiscriminate employment of escharotics foe 
the cure of uterine ulceration (against which I have so frequently 



DYSMENORRHEA. 187 

cautioned you), is very mischievous in this respect. The actual 
cautery, or its potential substitute, the potassa 

From cauterization. .. .,.,,. 

cum calce, destroys the cervical epithelium, 
and there is nothing left to prevent the consequent adhesive in- 
flammation from sealing up the outlet. Without their epithelium 
these surfaces grow together, just as your fingers would if the epi- 
dermis that separates and protects them were removed by a burn, 
and the surgeon who dressed it did not know enough to keep them 
apart until a new cuticle had formed. From considerable ex- 
perience in this class of cases, I am persuaded that contraction, cica- 
trization, and even atresia of the cervix are frequent sequelae of the 
milder, as well as of the more severe and reckless cauterization 
to which so many of our patients have been subjected before they 
come into our hands. The case just cited affords a good illustra- 
tion of this fact. Mrs. — had already suffered from dysmenorrhea 
for several years. The symptoms were sufficiently marked to 
suggest their Own solution and significance, even to a first-course 
student. But, as if to render her menstruation not only difficult 
but impossible, she, too, must be cauterized ! 

The symptoms of this disease are by no means limited to the 
site of the obstruction. Within the pelvis, and in the back and 

limbs, they are similar to those which ordinarily 

Symptoms. . . 

attend upon the menstrual effort. But in this 
case they are greatly exaggerated. When the patient is one 
who has never been pregnant, the uterine cavity is so small that 
the menstrual exhalation from its lining membrane soon fills it, 
and a feeling of distention and of extreme discomfort is induced. 
Aching and throbbing of the uterus, with uterine tenesmus are 
almost always present. In those who have borne children, and 
who have this form of dysmenorrhea subsequently, the womb, 
if not really more capacious, is yet more tolerant of the retained 
fluid. These women therefore do not commonly suffer so severely 
as those who belong to the former class. 

In both classes, however, the presence and pressure of the 
blood, which has no adequate outlet, excites the peristaltic con- 
tractions of the uterus with a view to over- 

Uterine tenesmus. 

come the obstruction and to force the now. 
The case then partakes of the nature of labor. The contractions 
of the uterus are much less powerful, because the fully-developed 



188 THE DISEASES OF WOMEN. 

fibres of its muscular coat are lacking. But it often happens that 
they are more painful than in real labor. The antagonism be- 
tween the body and fundus and the circular fibres about the inter- 
nal os uteri is very apt not only to cause intra-pelvic suffering and 
agony, but to develop a train of reflex symptoms such as are met 
with in abortion and in labor at term. 

Of the functions which are thus indirectly implicated and de- 
ranged, that of digestion suffers most frequently. Obstinate and 
painful vomiting is almost always present with 

Reflex disorders. pi n 

every return ot the menstrual cycle, whether 
it be prolonged and complete or not. It depends upon a stricture 
of the os internum, and comes on in the same manner that it does 
in rigidity of the os uteri during labor, or at the moment that the 
presenting part passes through the ring that is made of the enor- 
mously di]ated cervix. If there is ever so small a vent, and a 
portion only of the catamenial secretion escapes, the pain and 
emesis may subside. But, unless the flow comes on without any 
considerable delay, and pretty freely, the vomiting is likely to 
persist. And, what is a curious clinical fact, one that I am una- 
ble to explain, but which I have often observed, is that this vom- 
iting is almost certain to continue for about twelve hours. Our 
patient says that she vomited u every ten or fifteen minutes for 
twelve hours, but never for a less time." 

Some cases of obstructive dysmenorrhcea are met with in which 
the menstrual arrest and derangement have given rise to very 

complicated disorders of digestion, which many 

Indigestion. -, • • • -, 

physicians are incompetent to explain and to 
cure. The gastro-intestinal functions are involved just as they 
often are in the early months of pregnancy. Either through 
nervous or vascular connection between the uterus and the stom- 
ach, some portion of the small or large intestine, or the liver, or 
all these organs, the result is the various forms of indigestion, in- 
anition, constipation and bilious disease that so frequently arise 
from painful and irregular menstruation. 

In this, as in other varieties of dysmenorrhcea, it would be im- 
possible for the bladder and the rectum not to 
pifitton 1 and rectal c ° m " sympathize with the uterus in its prolonged 
effort to empty itself of its contents. Conse- 
quently there is, sooner or later, in almost all of these cases, more 



DYSMENORRHCEA. 189 

or less of vesical and rectal tenesmus. This incidental suffering 

corresponds with that proper to the first stage of labor. 

Coincidently with the tenesmus of the pelvic organs there is 

often, and indeed usually, a train of nervous symptoms which are 

more or less pronounced and alarming. Head- 
Nervous disorder. . .... 

ache, restlessness, insomnia, jactitation, spasms, 
and even convulsions are not infrequent, ail of which, however, 
are relieved as soon as the flow begins, exactly as in labor when 
the rigid os uteri has yielded and the presenting part has passed 
the point of obstruction. A very painful and distressing form 
of spasm to which some of these patients are subject is one in 
which the muscles of the back part of the head, of the neck and 
of the superior portion of the spine are affected, resulting in 
opisthotonos. Painful, cramping, clonic spasms of the flexors of 
the fingers and toes often occur. Some women are liable to a 
temporary blindness at these times, and you will observe the pupil 
to be sometimes very much dilated and again contracted. In 
those who are decidedly hysterical, there may be, during the par- 
oxysm, an evident disparity in the size of the pupils. 

In true obstructive dysmenorrhcea it seldom happens that the 

painful and persistent effort to restore the impeded flow finally 

causes it to become profuse. In this respect it 

Menorrhagia infrequent. ,.-«,■« , , . . , , -, . , 

diners irom the congestive, the spasmodic, and 
the membranous varieties, which are all of them likely to be either 
accompanied or followed b}^ menorrhagia. The amount of the dis- 
charge is not proportioned to the severity of the pain. The flow 
is scanty and intermittent, and, as in the case which I have 
related, the inter-menstrual period is generally lengthened and 
irregular. 

If the obstruction is congenital, or has come on from any cause 
before marriage, these patients are sterile ; for the same mechan- 
ical obstacle which interfered with the men- 
steriiity from obstructive gt rua l exit, will prevent the ingress of the 

dysmenorrhcea. J- © 

semen into the uterine cavity, and proper fecun- 
dation will be impossible. If the closure of the cervico-uterine 
outlet takes place in consequence of cauterization, or of post- 
partum inflammation in one who has borne a child or children, she 
also may afterwards become barren from the same cause. 



190 THE DISEASES OF WOMEN. 

If the dysmenorrhea depends upon congenital mal-formation 
of the cervix uteri this condition can be readily 

Diagnosis. . _•. 

recognized by the proper employment of a Sims 
speculum and the uterine sound, conjoined with the " touch." 

If it had its origin in puerperal inflammation ; if it has followed 
the extension of simple or specific vaginitis into the canal of the 

cervix ; if it depends upon some uterine ob- 

Physical exploration. ... _ n 

liquity, or the presence of a foreign growth ; or 
if it is the sequel of cauterization, the previous history and treat- 
ment of the case will facilitate the diagnosis. The simple fact 

that at the first attempt you fail to pass the 

Passing the sound. , 

sound into the uterine cavity should not lead 
you to decide the case to be one of obstructive dysmenorrhcea ; 
for in a healthy state of the uterine mucous membrane, and in 
the interval of menstruation, the internal os is in many cases so 
tightly closed that it requires considerable skill and experience to 
pass this instrument at all. But if the canal of the cervix is not 
absolutely impervious, a little patience and tact will enable you 
to succeed. You may sometimes insinuate a small Sims' probe, 
when a large sound, more especially a stiff one, could not be intro- 
duced without undue force and unnecessary suffering. I need 
hardly remind you that you will gain an entrance into the uterine 
cavity in this manner much more easily u at the month" than at 
any other time. 

You should remember that in this form of dysmenorrhcea there 
is not necessarily a complete and entire retention of the menses. 

The distinguishing characteristic of the disease 
The flow, and what it j s fa^ there is a mechanical impediment to the 

signilies. x 

monthly flow, which may or may not amount to 
a positive obstruction and arrest thereof. The failure of the prac- 
titioner to get a correct idea of this fact explains the proneness to 
blunders in the diagnosis and treatment of this affection ; for ob- 
structive dysmenorrhcea bears as little resemblance to endo-cervi- 
citis and to uterine ulceration as it does to perimetritis or to hema- 
tocele, and to confound them is both inexcusable and mischievous. 
The prognosis will vary with the cause of the disease, and also 
with the consequences of the menstrual irregu- 
larity. If the original organic defect, whenever 
it exists, can be remedied or compensated by surgical means, 



DYSMENORRHEA. 191 

recovery will follow. If the acquired or accidental obstruction, 
whatever it is, can be removed, the result may be favorable. 
Something, however, will depend upon the state of health, which 
is secondary, and which has been induced, directly or indirectly, 
by the persistent derangement of the menstrual function. If the 
dysmenorrhea has existed for years, the patient may be so ill with 
symptomatic endometritis, gastritis, gastro-enteritis, ovaritis, cys- 
titis, chronic hepatic and digestive derangements, tuberculosis, 
diseases of the nervous system, or a depraved condition of the 
blood, as to prevent her complete recovery. And this, although 
the ease and regularity of the flow have both finally been estab- 
lished. Therefore, you should be careful how you promise to 
perform a radical cure of this painful affection. 

Treatment. — One of the most successful and satisfactory 

achievements of modern gynsecolog}^ consists in having supplied 

us with the means of cure for most cases of this 

Surgical treatment. 

disease, .brom the nature of its causes, you 
will infer that the treatment of obstructive dysmenorrhea must 
be chiefly of a surgical kind. Internal remedies are suited to the 
relief, and possibly the cure, of other varieties of painful menstru- 
ation, but they are of little or no permanent avail in this. The 
•cause of the suffering is physical and mechanical, just as in a case 
of stone in the bladder, or of biliary calculus, and although, by 
the use of constitutional means, Ave may mitigate the pain and 
other incidental symptoms, yet the cure will depend upon the 
removal of the cause. 

If the seat of the stricture is at the os externum, a slight inci- 
sion may suffice to open the cervical canal. If, as most frequently 
happens, it is at the os internum, it will be most prudent to try 
the virtues of dilatation, and reserve the cutting as a dernier 
ressort. Dilatation is equally applicable to most cases of atresia 
of the cavity of the neck of the organ. 

When the passage is very narrow you will begin with a small 
copper sound, or probe, which may be passed every third or fourth 
day until the canal is somewhat enlarged. 
This may be followed by the ordinary sound, 
small bougies, laminaria, or slippery elm tents, the use of Atlee's, 
Priestley's, or Nott's dilators, and finally by the sponge tent. And 
although (in order to take advantage of the naturtL tendency to 



192 THE DISEASES OF WOMEN. 

expansion of the cervix), it is best to commence this treatment at 
the month, it must be continued during the inter-menstrual pe- 
riod also. As a rule, twice each week is as often as these opera- 
tions can be borne, and sometimes this is too frequent. 

As in passing the female catheter, so you will need to exercise 

considerable tact in the introduction of these instruments, more 

especially until, by repeated trials, you have 

Introduction of the neces-l eamec [ ^q COurse anC l curve of the Caiial ill 

sary instruments. 

each particular case. For its direction is so 
modified by the position of the patient, the fullness or emptiness 
of the bladder, the rectum, and even of the uterus itself, as well 
as by obliquities of the womb, that any rules which I might 
indicate would be of little practical service, unless you. should 
modify them to suit the case in hand. As a rule, the copper 
sound is preferable to the stiff one ordinarily employed. Sims' 
probe is too flexible, and might stick fast in the rugae of the cer- 
vix, or at the point of coarctation. If the womb is retro-flexed,, 
the patient must be placed in the semi-prone, and, if needs be, in 
the knee- elbow position, in order that the fundus and body of the 
organ may gravitate into their normal relations, and so that, in 
passing, the point of the sound may take the natural direction 
with reference to the axis of the superior strait. The most diffi- 
cult cases are those in which the cervical canal is tortuous and 
sinuous. You may or may not make use of the speculum to facili- 
tate the introduction of the sound, or of the tents. In all ordinary 
cases I prefer to pass them without, instead of through the specu- 
lum ; but perhaps you will do better with it. 

Much has been said of the frequent failure of dilatation of the 

cervical canal as a cure for this disease, and also of the injurious 

consequences that sometimes result from it. 

Failure of dilatation. . . . 

My own opinion, which needs a word of ex- 
planation, and which is based upon experimental and not upon 
theoretical grounds, is that, if properly employed, dilatation is 
more successful and less harmful than is generally supposed. I 
am inclined to attribute its failure in the hands of some physicians 
to a lack of caution on their part in the choice and application of 
instruments ; and also to too great haste to cure their patients, 
regardless of consequences. 

That cervicitis, cellulitis, peritonitis, spasms, convulsions, and 



DYSMENORRHEA. 193 

even hysterical tetanus, have sometimes followed the use of the 
dilators and of the sponge-tents is doubtless 
true, but there is little question that, if the cor- 
rect and complete history of these cases were written, it would be 
found that either the tents were composed of improper material, 
were too large, or were pushed through the cervix uteri too forci- 
bly, or that they were allowed to remain for too long a time before 
being removed. One of my patients suffered so severely that she 
could not tolerate a small ebony dilator, which was passed with- 
out difficulty, for more than ten minutes at a time. If I had not 
taken the precaution to remain with her and to observe the effect, 
but had left her with instructions that the instrument must be 
kept in place for some hours, she might have been dangerously ill 
from this cause alone. 

It may seem incredible, to the more advanced members of the 
class especially, that any intelligent physician should be so care- 
less as to introduce a slippery-elm or a sea- 

A barbarous practice. . 

tangle tent at his office, and alter wards permit 
his patient to travel by stage or by rail for some miles to her resi- 
dence, before it was removed ! But this is not an infrequent 
occurrence, more particularly with those who practice most 
largely among the lower classes in such a city as this. The inju- 
rious effects of such a custom should be charged to the abuse and 
not to the proper use of the tent. 

Providing there is no acute inflammation of the endometrium, 
or of the mucous lining of the cervix uteri, no ulceration, and no 

extensive or deep-seated cicatrices to be broken 
d-£at c ion s . ions concerning up, I think that the whole or any portion of the 

neck of the womb may be as safely, although 
not so rapidly dilated, as the female urethra. In exceptional 
cases, where the obstruction has been relieved by dilatation, it 
returns after six or eio-ht months. 

Mischief sometimes results from a lack of care in the choice of 
the material of which the tent is made. The slippery-elm tents 

are useful and available, and answer a very 

Of the various tents. _ ■ ' 

good purpose when they are smooth and small 
enough to permit them to take the shape of the canal through 
which they are to pass. But when a larger tent is requisite, they 
are too stiff and straight to suit many cases. A large sea-tangle 



194 THE DISEASES OF WOMEN. 

tent expands so slowly as to be practically useless, and to try to 
introduce several small ones at once, or, rather into the same cer- 
vix, that they may expand simultaneously, is a blundering and 
unsatisfactory operation. The hard rubber bougies are of various 
sizes, and can be bent into the desired form by heating them over 
a lamp, which items are much in their favor ; but they are too 
blunt for use in the early stages of treatment, when the passage 
is very narrow. If the sponge tent is an old one, it is apt to be 
hard and unsuitable. Moreover, when kept in contact with the 
cervico-uterine fluids, such a bit of sponge will more readily de- 
compose. Now that our sponge tents are carbolized, however, it 
is quite probable that some of the evil consequences attributed to 
the use of this instrument will be omitted in future. 

The rashness and injudicious haste with which dilatation has 

sometimes been practised, have excited a prejudice against it in 

the minds of many. There are physicians who 

Precautions in practising undertake to dilate the contracted cervix in 

dilatation. 

obstructive dysmenorrhea with the same dis- 
patch with which a surgeon would amputate a limb, or excise the 
tonsils. The whole operation must be performed at once, and the 
unfortunate results that may follow are almost invariably attrib- 
uted to the instruments used, instead of to the lack of discrimina- 
tion and judgment on the part of the operator. The proper plan 
is to " feel one's way," as the phrase is, and to take plenty of time 
in order to overcome the obstruction without any serious shock 
to the patient's system, or any risk of the diseases which I have 
named as contingent upon this operation. If }-ou cannot succeed 
in one month, it is better to take two or three, or six, if need be, 
and to make gradual progress towards a cure, than to be precipi- 
tate and finally to bring yourselves to condemn this expedient al- 
together. The cautious and persistent dilatation of the cervix 
was the only means employed in the case cited at the opening of 
this lecture. I have resorted to it in many other instances with 
equally good results. 

When, however, you have made a faithful trial of dilatation, 

and it has failed to bring the hoped-for results ; 
^jndsion of the cervix r, if after having afforded temporary relief, 

there is a serious relapse, and you are satisfied 
that a radical cure is not possible by this means, incision of the 



DYSMENORRHEA. 195 

<eervix is a final resource. I do not say that you should never 
have recourse to this latter expedient before having tried the 
.nethod by dilatation, but only that I think it more prudent and 
preferable to hold this operation in reserve, both because it is 
beset with more real danger, and also because, if it will answer, 
die simpler means is the safer of the two. There are cases, un- 
doubtedly, in which the incision or slitting of the cervix is indis- 
pensable. 

Kapid and forcible dilatation of the cervix is very popular with 
some gynecologists for the cure of dysmenorrhoea and sterility as 
well as for opening of the cervix for the 
Rapid dilatation. purpose of intra-uterine exploration and opera- 
tion. Of the several instruments devised for 
this purpose, all of which are savage unless very skilfully and 
cautiously used, Goodell's is the best. In employing it so as to 
expand the cervix at one sitting, the patient should be placed pro- 
foundly under an anaesthetic, and should be kept in bed several 
days afterwards. It may or may not be best to follow this opera- 
tion with the introduction of the hard rubber stem, which will 
have the effect to keep the cervix open and to prevent any irregu- 
lar cicatrization within its canal. 

This method of rapid dilatation is contra-indicated by active 
inflammation within or about any portion of the uterus or pelvis, 
and also by the near approach of the menses. It should be 
practised within a week after the flow has ceased, a precaution 
that will give time for the parts to heal before the monthly cycle 
has returned. It may be necessary to repeat it once a month 
for two or three times. Usually, we do not need to persist so long 
with dilatation in treating dysmenorrhoea as in the treatment of 
sterility. 

This rapid method, if carefully done, is more satisfactory in 

every way, than the old Mcintosh method 

Dilatation by graduated which was first practised many years ago and 

bougies. which consisted of the use of graduated 

bougies that were passed and allowed to remain 

for a little while. (Fig. 45.) The introduction of these blunt 

bougies is often very painful, and the relief that they afford is not 

-lasting or permanent. 



196 THE DISEASES OF WOMEN. 

Prof. Simpson first conceived the idea of slitting the cervix so* 
as to overcome the constriction of its canal and 
incision of the cervix, to open up a way f or the ready exit of the men- 
strual flow. His operation, which was exten- 
sively practised by Sims and others has gone out of date. The 
form of this operation, most commonly resorted to in this country, 
was that of Sims, which consisted in passing one blade of a pair 
of curved scissors within the os uteri, and as far up as the junc- 
tion of the cervix with the vaginal roof. The scissors were then 
closed so as to cut through the cervix from the outside. The 
instrument was then turned 'round and the opposite side was- 
mutilated in the same manner. It was in this way that those who 
had not borne children were made to suffer from an artificial lac- 
eration of the cervix which was very similar to the accidental 
wound of the same organ in the mothers who are now the subjects 
for Emmet's operation. 

I very much prefer the operation of discission as it was advised 
by Peaslee. It consists in the uniform division 
Discission of the cervix, of the cervical canal from the internal os down- 
wards through the external os uteri, but without 
a complete and unnecessary section of the vaginal cervix. The 
incision is bilateral and is made without repetition. The steps 
of the operation are few and simple, the patient should be anaes- 
thetized, not only because the operation would be somewhat pain- 
ful, and because there might be such a degree of hemorrhage as 
would alarm her, but also because it is best to have her lie quietly 
during the operation. The hips should be brought to the edge of 
the table and the patient placed in Sims' position. The next step 
after having retracted the perineum with a Sims' speculum, is to 
seize the cervix and bring it into view. This can be done with a 
trusty tenaculum, and has the double effect of rendering the man- 
euvre of passing the uterotome more readily, and of lessening the 
risk of hemorrhage, for to cause the uterus to descend in this way 
is practically to place its lower segment in a tourniquet. 

The uterotome that was devised by Peaslee (Fig. 21) is prefer- 
able. It carries two concealed blades, the expansion of which, after 
it has been introduced, is regulated by a screw in the handle. It 
may be gently and carefully passed, like the uterine sound 
just within the internal os, and when the blades are slightly 
spread, it should be slowly and carefully withdrawn, so as to 
cut both sides of the membranous canal as it passes out. It 



DYSMEXORRHCEA. 197 

may be requisite to repeat the operation two, or even three 
times. 

Without great care in its performance, there is danger of sud- 
den and fatal haemorrhage, hematocele, peritonitis, cellulitis, or 
endo-metritis. The risk of these accidents is 
in ratio with the extent and depth of the in- 
cisions which are made through the os internum, and also in the 
abdominal portion of the cervix uteri, at a point superior to the 
insertion of the vagina. 

You should remember that in their distribution the uterine 
arteries pass downwards on either side of the womb, to its neck, 
and then ascend in a tortuous course by the side of the organ 
between the layers of the broad ligament anastomosing with the 
ovarian artery. In order to avoid cutting this artery or any of 
its branches at the internal os uteri, I recommend you to cut from 
before backwards and vice versa, i. e., towards the rectum and the 
bladder, instead of laterally, being careful not to cut tar toward 
either organ. 



Fig. 21. Peaslee's Uterotome. 

After the operation she should be kept in bed for a number of 
days. Fatal peritonitis has been known to 

Precautions. " . _ . . , . 

occur, trom a lack ot care in this regard, as late 
as the tenth day after the incision. 

In every case the patient and her immediate friends should be 
made acquainted beforehand with the nature of the proposed 
operation, the dangers with which it is beset, and the possibility 
that it may need to be repeated before the cure can be considered 
complete. 

OBSTRUCTIVE DYSMENORRHEA FROM POST-PUERPERAL ATRESIA. 

Case. — Aug. 6th. This woman is 35 years of age. She gave 
birth to a child eight years ago, which lived but five months. 
One month after the child's death her menses appeared, but never 
have been regular, and continue but one or two days. Previous 
to the flow she has sharp uterine pains ; following it the pains 
are dull and heavy, she also has pain in her hips. Including the 



198 THE DISEASES OF WOMEN. 

ante-menstrual effort and the duration of the flow, her sickness 
lasts for ten or twelve days. 

Local examination revealed an almost complete stenosis, or 
closure, of the cervix uteri. The os was barely large enough to 
admit of the introduction of a Sims' probe. This lesion was evi- 
dently the result of puerperal endo-cervicitis from which she 
must have suffered eight years before, for she is positive that she 
has not been pregnant, neither has she had an abortion since that 
time. The treatment was begun in the presence of the sub-class 
by the introduction of the uterine sound, and the patient was. 
directed to take belladonna 3. 

Aug. 15th. The cervix was exposed and expanded by the use 
of Nott's dilator. Being on the eve of menstruation she was 
directed to take gelsemium 3, every two hours. (See Fig. 22.) 

Aug. 20. She has flowed a little more freely than usual since 
the dilatation, and is now menstruating. 

Aug. 27. Complains of great dizziness, she does not flow 
freely enough. The os uteri was again dilated with the same 
instrument, and found to be less rigid than before. 

Aug. 29. The same operation was repeated, after which Cham- 
ber's split rubber stem was introduced, and, unless it should: 
prove to be too painful, was directed to be left in position until 
evening when it was to be removed. Belladonna 3. (Fig.23.) 

Sept. 5. Upon passing the dilator, the internal os was still rigid. 
The cervical canal was thoroughly dilated and the patient ordered 
to take arnica 3, three times a day. 

Sept. 12. She is improving. The cervix was again dilated 
and the same remedy continued. 

Sept. 19. She is much better; dilatation was practised as. 
before, there being very little obstruction to the passage of the 
instrument. Belladonna 3. 

Oct. 3. She is still improving. No more headache, or flushed 
face, but feels more like herself than she has for years. The 
operation was repeated, and the same remedy continued. 

Oct. 17. She had her flow for three days last week. It was 
easy, and natural in quality. She is very happy over the result 
and delighted with the relief obtained. The same remedy was 
continued. 

Dec. 5. She is still improving; the menses have been free^ 
prompt, and painless. At the last period the flow continued four 
days. The sound passes very easily, and the depth of the uterus 
is three and one-half inches. She was recommended to continue 
belladonna 3. For some weeks she continued to come occasion- 
ally to the sub-clinic, when the dilation was practised, especially 
in advance of the period, as prophylactic of the dysmenorrhea. 

This is an exceptional case, but it will serve to illustrate two or 



DYSiMESORRHCEA. 199 

three points that are of practical interest. The lesion undoubt- 




Fig. 22. Nott's Dilator. 

edly originated in a form of puerperal metritis, but we may safe- 
ly infer that the inflammation was limited to 
the cervical portion of the uterus. For if it 
had involved the lining membrane of the uterine 

cavity, or, in other words, if she had had puerperal endo-metritis, 



Dates from puerperal 
ity. 




Fig. 23. Chambers' Stem Pessary. 

there would have been sub-involution, menorrhagia, and increased 
depth of the organ as necessary sequelse. Instead of these con- 
ditions having been entailed upon our patient, 
?he result of adhesive however, we have such a stenosis and oblitera- 

inflammation. , . ~ . , ., , t-iti 

tion ot the cervical canal as could only have re- 
sulted from adhesive inflammation of its lining membrane. The 
poor woman, who knows next to nothing of her child-bed expe- 
rience, cannot tell us whether she had any inflammation at all, 
and this is a sample of the information that you will derive from 
a large class of post-puerperal cases. 




A clinical lesson. 



Fig. 24. Atlee's Dilator. 

The practical point in treating such a case as this is not to rely 
too exclusively upon internal remedies alone, 
and, above all things not to incise the cervix in 
a careless, off-band way, regardless of the previously existing 
inflammation which has been so prominent a facte r in causing the 
obstruction and the dysmenorrhcea. If we had cut this cervix 



200 THE DISEASES OF WOMEN. 

freely in the beginning of our treatment, or if we had dilated it 
very rapidly and forcibly, the patient might have had cellulitis or 
pelvi-peritonitis in consequence of our temerity. The same 
result has sometimes followed the use of the sponge tent under 
similar circumstances. It is much safer and quite as certain to 
bring about a good result if we proceed more slowly. 

In this connection I am satisfied of another thing, which is 

that, when the neck of the womb has been narrowed by serious 

inflammation, whether puerperal or traumatic, 

f ' A ^ t h ra ; indication or from an excess of local treatment, it is 

for anaesthetics. 

always safer not to administer an anaesthetic 
before performing any surgical operation for its cure. The sensi- 
bility of the patient, if she is not altogether too timid and 
nervous, will help to decide how far we should proceed with the 
incision or the dilatation, and to keep us from putting our 
patient's life in jeopardy. 

The object in the introduction of the Chambers' stem, was to 
keep the canal of the cervix open, and by steady 
The use of the uterine pressure to increa se its calibre. This little in- 
strument is especially useful in the case of 
women, who although they have atresia, have once borne chil- 
dren. (See Fig. 23.) 



LECTURE XII. 

OBSTRUCTIVE DYSMENORRHCEA FROM STENOSIS OF THE UTERINE 
CERVIX AND PELVI-PERITONITIS. 

Obstructive Dysmenorrhea from stenosis of the cervix. Case— rule for operations on the 
cervix— post-surgical peritonitis— obstructive dysmenorrhoza from retro-flexion. Case— 
causes, symptoms, diagnosis, sequelae and treatment of dysmenorrhea from retro- 
flexion. Neuralgic dysmenorrhcea. Case.— The importance of physical signs— a neu- 
rosis—symptoms — relation of the flow to the degree of pain — treatment. Spismodic 
dysmenorrhcea. Case.— effect of stimulants— do. of opiates— medicinal aggravations— 
gelsemium and other remedies. 

The following is the history of another very interesting case 
-of obstructive dysmenorrhcea : 

Case. — Miss — , a Swede aged 24, has been ill for eight months, 
she suffers from very severe pain which comes two weeks in 
.■advance of the monthly period, and continues until the flow stops. 
The flow itself is very slight, sometimes coining almost drop by 
drop, and never lasting more than three or four hours. After the 
pain begins, the distress within the pelvis increases until, at the 
time of the discharge she is so wretched that she is forced to quit 
her work and go to bed. When the flow stops the blood is deter- 
mined to the head and face, and for a day or two she is almost 
insane with a headache, which gradually wears away so that she 
can resume her duties. At these times she is very much annoyed 
by a fine rash which appears on her face and neck. 

She gives an intelligent account of herself, and says, that two 
years ago her sufferings were of precisely the same character. 
When they became unbearable she consulted a physician, who 
made an operation upon the neck of the womb, which, from her 
understanding of it, must have consisted in its incision perpendic- 
ularly, after the manner of Simpson or of Sims. For a little while 
her sufferings were very much relieved. The pain and congestion 
passed away, and the flow became more free and natural, than it 
•ever had been before. But, in consequence of over work, with a 
lack of care, she soon felt an increased tenderness and pain within 
the pelvis and about the neck of the womb, after which, the old 
symptoms returned. Local examination, found the cervix nar- 
row, and elongated, very sensitive, and almost impervious to 
the sound. The os-uteri had the shot-hole form, and there was a 
great deal of tenderness with manifest signs of chronic pelvi- 
peritonitis. The treatment was be#un with careful dilatation of 
the cervix, and the prescription of belladonna (5, four times a day. 



202 THE DISEASES OF WOMEN. 

This treatment was continued for several months, with a decided 
improvement of the local and general symptoms; but the relief 
was only partial and not permanent. When the dilatation was 
persevered with, and she did not allow more than one period to 
pass without reporting herself to the sub-clinic, she got along very 
well, the flow would come promptly and would continue for two 
or three days. But if she staid a way and" neglected herself, she 
soon relapsed into her old experiences. Other remedies, includ- 
ing 1 o-elsemium and iomatia were ffiven from time to time. 

This case is analogous to that shown you at the close of my 
last lecture. But that, as you will remember, dated from childbed 
while this, in all probability, is congenital. It 
Rule for operations j s a ru ] e among oynsecolooists that all opera- 

on the cervix. . *" l . c 

tions which are designed to open the cervix are 
dangerous when there is inflammation about the uterus and within 
the pelvis, but more especially when there is peritonitis or 
cellulitis. This explains our delay in the use of the sponge tent 
as a more active means of dilatation. The pelvic peritonitis has 
therefore been in the way of a radical cure. 

From what we can learn it is very doubtful if our patient had 
this form of pelvic inflammation before she was operated upon two 
years a^o. You will often meet with cases of" 
jpost surgical periton- thig kindj f the sequelfie f careless and excess- 
ive slashing of the cervix are very common in? 
our day. And I urge you not to forget that post-surgical periton- 
itis needs to be handled very carefully. 

The occurrence of the eruption upon the face is often met with 

in cervicitis and also in dysmenorrhea, but its exact relation to 

these conditions is not known. Sometimes this 

The facia eruption „ 

rash disappears and is transferred to the uterine 
mucous membrane with an aggravation of the menstrual symptoms,, 
and facial eruptions often result from an excess of local treat- 
ment, more especially from cauterization of the uterine cervix, in 
scrofulous subjects. In this case we will first strive to cure the 
pelvi-peritonitis, and afterwards proceed, if necessary, to opera- 
tive interference. She will take belladonna 3, three times a day. 

OBSTRUCTIVE DYSMENORRHEA FROM RETROFLEXION OF 2 HE 

UTERUS. 

Case. — Mrs. N. set. 28 years, is the mother of two children, the 
youngest of which, if it had lived, would now have been seven 



OBSTRUCTIVE DYSMENORRHEA. 203 

years old, and since the death of which she has not been well. 
Her confinement occurred in the country where she only received 
the attention of the volunteer nurses in the neighborhood. After 
labor she evidently had a pretty severe attack of metritis, with 
which she was ill for a long time. The child lived four months, 
during all of which time she continued to nurse it. When after its 
death, her menstrual function was resumed, the flow was observed to 
be scanty in amount, and thick and coagulated in character. There 
was much intra-pelvic pain and distress, a bearing down in the 
rectum, aching in the sacral region, and obstinate constipation. 
The suffering at the period sometimes begins as early as ten days 
in advance of the flow. It generally commences about a week 
before, and during the twenty-four hours preceding the beginning 
of the discharge, is sometimes so severe as to make her very ill 
indeed; but as soon as it comes on freely her acute sufferings 
subside. 

At the appproach of the monthly crisis there is a manifest 
determination of blood to the head and face, and sometimes to the 
lungs and heart. In the former case she suffers from a distracting 
headache which nothing but the eruption of the menses relieves. 
This headache is accompanied by an intolerance of light and sound, 
and excessive nervousness and tension of the mental faculties. 
Sometimes she can divert herself from the thought of suffering by 
a strong effort of the will, as by setting to work violently, or by 
reading intently. The pains in the back and limbs, however, 
prevent her from being much upon her feet while the flow is 
threatening, and usually, until it has ceased altogether. 

When the head symptoms are less pronounced, or lacking 
entirely, she has dyspnoea, which prevents her from lying down, 
and cardiac oppression and palpitation that are very distressing to 
witness. Her husband and friends have often thought that she 
was surely about to die from them. Sometimes there is choking, 
and even entire inability to swallow. Again the respiration is 
hurried and panting, and she has fits of a smothering suffocation, 
resembling spasmodic asthma. She imagines that she has heart 
disease, and at least one lugubrious doctor has told her that, one 
of these days, she will die suddenly of an obscure cardiac affection. 

Careful ancl repeated examination of her chest has failed to 
disclose any evidence of organic disease either of the heart or of 
the lungs. There is not the least sign of trouble there excepting 
at the period, and then it alternates with the brain symptoms. 

The uterus, however, is retroflexed, curved upon itself like a 
retort, but more acutely. The os is in situ, but the fundus uteri 
falls over backwards and is felt pressing against the anterior wall 
of the rectum at the Douglas' cul-de-sac. There is no ulceration 
or other visible lesion of the uterine cervix. 



204 THE DISEASES OF WOMEN. 

It may, perhaps, have occurred to you as somewhat remarkable 
that a majority of the cases brought to your notice in this clinic 
are of long standing, and chronic in their history. There are 
three reasons for this fact: 1st, in the greater portion of cases of 
the diseases of women the physician is not consulted in the early 
stages of the complaint; 2d, no otner ailments are so prone to 
relapse and to self-perpetuation; and, 3d, there is no other 
department of medicine or surgery in which such egregious errors 
lire committed in diagnosis, and therefore in treatment, as in 
this. In the light of this explanation, it is not a mere coincidence 
that these two chronic cases have come before us this mornina*. 
They represent a class in which the ill effects of delay and of a 
mischievous treatment are conjoined, — a class that will give you a 
great deal of trouble bye and bye. 

In retroflexion of the womb the organ is flexed or bent back- 
wards, the fundus being towards or against the anterior wall of 
the rectum, and the cervix but little if at ail 
displaced. The point of curvature which is the 
most acute is, therefore, the posterior cervical wall below the 
internal os uteri, and opposite the lower margin of the peritoneal 
coat of the womb in front. Virchow and others have taught 
that the fact, that the external or serous envelope of the uterus 
being deficient upon the anterior surface of the neck of the womb, 
predisposes to the various kinds and degrees of flexion to which 
this organ is prone. 

Other causes of retroflexion are such as are common to uterine 
deviations of different kinds. These are, too violent exercise, 
jumping, skating, calisthenics, constipation, 
habitual retention of the urine, prolonged sitting 
or standing, tight lacing, fibroids, polypi, etc. There are two 
especial causes, however, to which I am inclined to attribute a 
large proportion of the cases of retroflexion which come to our 
notice. The first of these is the species of post-puerperal hyper- 
trophy which follows abortion prior to the fourth month. 

You are aware that the structural changes which occur in the 
womb in the early months of gestation are usually, and almost 
exclusively, confined to the body and fundus of the organ. The 
cervix does not participate in these changes until about the tenth 
week. Now, if abortion occurs under these circumstances, the 



Causes. 



OBSTRUCTIVE DYSMENORIOKEA. 205 

body and- fundus of the uterus being disproportionately developed, 
and the cervix somewhat softened and relaxed, but otherwise 
unchanged at the time of the delivery, the accident will be very 
likely to predispose to a flexure of the organ in some direction, 
either anteriorly, posteriorly, or laterally. More especially would 
this be true if following the abortion, and from any cause whatever, 
the proper retrogressive changes in the uterine structures took 
place irregularly, or were arrested altogether. And so it may 
happen that a chronic retroflexion shall date from an early abor- 
tion which took place years before. 

The other cause to which I have alluded is a delay or obstruc- 
tion to the ready exit of the menses . That dysmenor rhcea may ca use 
this kind of uterine deviation is just as true as that an acute flexion 
of the womb sometimes gives rise to very painful menstruation. 
In not a few cases these causes act and react, and exceptionally it 
may be quite impossible to say which is the cause and which the 
effect. But where the internal os is either spasmodically or 
mechanically closed, so as to prevent the escape 

Dysmenorrhcea,either ... , , . . . 

a causeoraa effect. oi the menstrual discharge, the uterine tenes- 
mus maybe so prolonged and violent, and with- 
al exercised in such a direction, through the conjoined contraction 
of the diaphragm and abdominal muscles (as in true labor), as to 
force the fundus toward the hollow of the sacrum without dis- 
placing the cervix. In those cases ol dysmenorrhcea which are 
characterized by hours of suffering before the flow appears, and 
which correspond with the first stage of parturition, the true 
uterine axis is certain to be changed: and deviations at the month 
are very apt to perpetuate themselves. 

These contingencies of gestation and of menstruation should 
not, therefore, be lost sight of when you study the etiology of 
retroflexion of the uterus. 

The symptoms vary in different cases, depending somewhat upon 
the degree of the displacement, and the susceptibility of the 
patient to nervous and other complications. 
The pain and distress may be near or remote. 
Such pains within the pelvis, with rectal urging, paralysis of the 
bowel and faecal accumulation, weakness, and coldness of the 
lower extremities as our patient complains of, are very common. 
Nor is the congestive headache, the precordial oppression, or the 



The touch.' 



206 THE DISEASES OF WOMEN. 

cardiac irregularity by any means rare. . Naturally enough these 
symptoms are aggravated each month. For, in the effort to 
empty itself, under the disadvantage of an acquired deformity, the 
suffering is the more severe and protracted. At this time not a 
few such patients have hysterical symptoms, which simulate other 
diseases, and may mislead the doctor. Or this incident cause may 
finally develop a species of reflex insanity, and thus render the 
patient a most pitiable object. 

By the "touch" we find, in a case of retroflexion, that, while 
the os and cervix uteri are where they should be, there is a tumor 
at the Douglas cul-de-sac. On tracing the out- 
line of this tumor we find that it is retro-cervi- 
cal, smooth, regular, and that it is connected, by a curve which 
is more or less acute, with the upper extremity of the neck of the 
womb. If necessary, the rectal touch may be resorted to in con- 
tinuation. In a majority of cases this tumor is reducible by 
steady pressure, or by placing the patient for a little in the prone 
position. 

But the best diagnostic sign is afforded by the introduction of 
the sound. If, when the instrument has passed the os-internum, 
its point shall turn backwards instead of for* 
' wards, towards the hollow of the sacrum, instead 
of towards the bladder, there will be little difficulty in deciding 
upon the kind as well as the degree of the displacement. It may 
happen, however, that the deviation of the uterus shall be so 
intimately associated with the dysmenorrhcea as only to occur tem- 
porarily, and for a limited period, at the month; in which case 
this sign of retroflexion would be present at one time, and not at 
another. Owing to this very simple reason, I have known of some 
grievous errors in the diagnosis of retroflexion. For it almost 
never happens that the degree of this displacement is the same for 
two successive weeks, and it is possible that, during the inter- 
menstrual period, the organ might be spontaneously reposited, a 
result which we would not expect in retroversion. 

The prognosis turns chiefly on our ability to remove the cause, 
whatever it may have been ; on the general state of the patient's 
health; the exemption from acute or malignant disease, either in 
the uterus, the ovaries, or elsewhere; and on a regulation of the 
contingencies of menstruation in such subjects. Even in those 



OBSTRUCTIVE DYSMENORRHEA. 207 

cases which are least severe and chronic it is not safe to promise a 
speedy and permanent cure. In old cases a radical cure is some- 
times impossible because the tissue of the uterine wall at the seat 
of flexion, in the angle formed by the bend of the organ, has been 
so atrophied that it will not afford the proper support to the 
womb when it is upright. 

One frequent and troublesome sequel of letroflexion is sterility. 
Another is a tendency to abortion, in consequence of the inability 
of the uterus to right itself and to rise above the 
brim of the pelvis, in order to be properly de- 
veloped. A third :ind not infrequent result of this deviation is 
the induction ot a species of pathological moulting of the uterine 
mucous membrane at each catamenial period, causing membranous 
dysmenorrhea . 

Treatment. — In a case like the one before us our duty is plain, 

Nothing- could be more obvious than the necessity for lifting the 

uterus into its proper position, and for keeping 

Indications. ,, . .f. , i ' o 1 V- a. 

it there when it is restored, buch an expedient 
is not requisite in all cases of retroflexion indiscriminately. But 
whenever the displacement interferes with the readiness and free- 
dom of the menstrual flow, it must be corrected; otherwise the 
most severe suffering may be induced, and the gravest lesions 
entailed upon the patient in consequence. 

Fortunately, as a rule, the reduction of the dislocation is not 
difficult. Careful manipulation with the sound, a Sims' or Guern- 
sey's elevator, Elliott's sound, or better still with 
^Reposition of the or- the index finger COD j oined w ith the proper posi- 
tion of the patient, will be sufficient. So much 
more easily is this deviation corrected than in retroversion, that it 
is seldom necessary to manipulate Avith the linger introduced into the 
rectum. The patient should lie either in the semi-prone, or prone po- 
sition, so that gravity may aid in the correction of the misplacement. 
In some cases it is quite sufficient to pass a Sim's speculum and re- 
tract the perineum, when, the vagina being filled with an unusual 
quantity of air, the uterine body and fundus will immediately be 
lifted into position. At other times the bladder or the rectum 
may require to be evacuated before attempting to reposit the 
uterus. 

But, having fulfilled this indication, how shall we keep this 



208 



THE DISEASES OF WOMEN. 



Keeping it ir place. 



intractable organ from deflection in the future? My own plan of 
procedure is to confine the patient to the bed or 
couch, and, as much as possible, to the semi- 
prone position during the whole menstrual period; to remove all 
ligatures from about the body ; to prevent faecal accumulation in 
the rectum, and the retention of urine, also, and to facilitate the 
prompt escape of the menstrual secretion, when it is recmisite,by 
the artificial dilatation of the cervix uteri. In many cases I have 
passed a sponge tent, or an ebony dilator, some hours, or perhaps 
the night before the time for the flow to begin. By this means 
the instrument not only served to expand the internal os uteri, and 
thus to remove any particular necessity for a parturient effort on 
the part of the uterus, but likewise also to act as a means of keep- 




Fig. 25. Hard Rubber Dilators. 

hig the organ erect until the discharge was freely established. I 
prefer these hard-rubber dilators, which, as you see, are of vari- 
stem dilators ous sizes, because, by heating them over the gas 

or lamp, they can be bent to suit individual cases 
more accurately than the slippery-elm or sea-tangle tents could be. 
Moreover, it will not unfrequently happen that the uterus will 
tolerate this instrument for several days, in which case it may be 
left in situ while menstruation is going on ; and unlike the sponge, 
it will not interfere with the exit of the catamema. 

Some of my patients with retroflexion have worn these stem 
dilators for a night, or for twenty-four hours or more, each week 
during the inter-menstrual period. Others, again, who could tol- 
erate them, have carried them within the canal of the cervix, with 
impunity, for a fortnight or more consecutively. But you m ust not 
suppose that such foreign bodies are not sometimes mischievous 
and harmful, when they are introduced or kept for any considerable 



OBSTRUCTIVE DYS3JENOKKHCEA. 209 

thw in the cervical canal. There are cases in which they could 
not be borne for the space of half an hour, without inducing such 
alarming diseases as peritonitis, cellulitis, cramps or convulsions. 
Fortunately, however, when the retroflexion and dysmenorrhea are 
combined, these means of dilatation will usually do no harm " at 
the month," and this is the period of their greatest utility. 

Another means of retaining the uterus in position, is to place 
a support for it in the posterior cul-de-sac. Grariel's air pessary 
might serve to cushion the organ and to keep its fundus thrown 
forwards, or a pad of cotton or sponge might be applied in the 
same manner. A physician of my acquaintance extols the use of 




Fig. 36. Cutter's Pessary. 

a roll or a wad of oakum thus applied. Thomas's Cutter's pessary 
sometimes answers the same purpose, and Hodges' or Thomas' also 
are serviceable in others. 

I feel the more inclined to emphasize the importance of keeping 
the uterus in its proper place, when it tends to retroflexion, be- 
cause it is unreasonable to suppose, that where the displacement 
is allowed to continue, the structural lesion which has caused it 
could be cured while its proper circulation, innervation, and nutri- 
tion are so seriously impaired. Even the slightest atrophy of the 
tissues at the point of flexure could not be cured while the uterus 
remains bent upon itself. Therefore, this indication precedes and 
anticipates the selection of the remedy or remedies. Indeed, in 
most cases, we shall find that when it has been accomplished, there 
are but very few symptoms remaining. In this respect, and in 
point of fact, the retroflexion of the uterus is a veritable disloca- 
tion. 

Having removed the local cause, and corrected its more direct 
consequences, the symptoms and lesions that remain are to be 

14 



210 THE DISEASES OF WOMEN. 

treated to the best of our ability, and by such internal remedies 
as are most appropriate. The proper time for 

Msdicinal treatment. . . . „ . . 

their employment, in this case, lor example, is in 
the inter-menstrual period. For then the way is clear, and we 
shall make a more decided impression than if we prescribed our 
remedies regardless of proper conditions and indications. 

We will now pass this ebony dilator, in Mrs. N.'s case, and if it 
does not cause very much pain, leave i t in the cervical canal for a day 
or two. The operation will be repeated according" to circum- 
stances. Meanwhile she will take a dose of belladonna 3, every 
three hours. 

NEURALGIC DYSMENORRHEA. 

Case. — I was called September 1(3, 1860, to visit Mrs. , 



aged 21, of tall, slender habit, nervo-sanguine temperament, and 
most amiable disposition. Found her suffering from intense 
neuralgic pains in the uterine, lumbar and ischiatic regions. Hei 
period had passed as usual more than a fortnight before, and for 
ten days previous to my first visit, these paroxysms of neuralgia 
had taken on an intermittent type, recurring every afternoon. 

My patient had first menstruated at the age of thirteen. She 
has never had any retention of the flow, but has always suffered 
extremely. Has been married about six months, but has not been 
pregnant, nor has she experienced the least change in her men- 
strual symptoms since her marriage. In February last, while 
residing in Western New York, she had a severe attack of diph- 
theria. This was followed by rheumatism, or rheumatic neuralgia 
of the left arm. When the menses returned at the next month, 
there was a metastasis of this pain to the lumbar and uterine re- 
gion. From that time until the present the "period" has been 
characterized by the most intense sufferings. Indeed there is no 
very decided remission of her suffering excepting for about one 
week in advance of the flow. For the day and night immediately 
preceding the appearance of the catamenia her sufferings are al- 
most intolerable. She becomes exceedingly nervous, and restless, 
or wild with excitement, delirious, or has cramps and spasms of 
the most frightful kind. 

For the relief of the neuralgia, I prescribed, in turn, arsenicum, 
cocculus, coffea, hyoscyamus, and with the return of the scanty 



NEURALGIC DYSMENORRHEA. 211 

flow, apis mellifica, and caulophyllin. These remedies were re- 
peated at reasonable intervals, — each of the two latter palliating 
somewhat the severity of the symptoms at first, but subsequently 
proving of no effect. 

On the afternoon of the third day of the flow, she had severe 
hysterical convulsions, which were controlled by moschus in the 
third decimal trituration. This remedy, however, only made her 
the more sensible of her sufferings. 

After treating her most assiduously through the next menstrual 
interim — during which time she experienced but partial relief 
from the neuralgia, — the recurrence of the catamenia, on the 
25th of October, was marked by precisely the same symptoms as 
before. It was impossible to discover that a single point had been 
gained by some six weeks' faithful trial. 

Convinced of the existence of a local cause for the mischief, I 
proposed an examination per vaginam. Passing my finger care- 
fully toAvards the external os uteri, — the vaginal walls being al- 
most as closely contracted as in vaginismus, and the patient in 
intense pain, — I found the womb in situ, and the lower extremity 
of the cervix.quite normal to the touch. Ongoing a little higher, 
in order to ascertain the condition of the upper portion of the neck, 
my finger fell into a groove which extended all the way around the 
organ at the junction of the vaginal portion of the lower seg- 
ment of the womb. This very marked constriction led me to 
infer that there was a decided spasm of the circular fibres of the 
neck of the uterus, or in other words a stricture of the cervix, 
leaving it much in the same condition as if it had been ligated at 
that point. 

Simpson's sound was passed without difficulty as far as the os 
internum, but by no manipulation could I succeed in carrying it 
into the uterine cavity. A smaller probe, made expressly, was 
afterwards introduced, then the sound, and finally this little silver 
instrument, which resembles one of Simpson's intra-uterine pes- 
saries, was passed completely through the cervico-uterine canal. 

This instrument was carefully adjusted at nine in the evening, 
one clay in advance of the expected flow. She was instructed to 
lie quietly upon her back as long as possible, in order that it 
might not be displaced, or drop away. It was retained until 
twelve o'clock — three hours — when it came away of itself. 
After this she enjoyed a tolerably good night's rest. The next 



212 THE DISEASES OF WOMEN. 

morning the flow came on, and more freely than usual, and with 
less of suffering than she had experienced for years before. Once 
only during this period, the flow became scanty, when a few doses 
of apis mellifica 3, brought it on again, but without any return of 
the neuralgia. 

Contrary to my expectations, the relief seemed permanent. 
During the next inter-menstrual period she appeared to be quite 
well ; rode out almost daily, attended evening parties, danced and 
sang (for she was a favorite singer), and was indeed the happiest 
woman in the city. The only subsequent trouble experienced was 
six months later, when she had a slight attack of uterine colic, 
which was j)romptly relieved by ignatia3. 

There are several points of interest connected with this case, 
the practical relations of which may interest you. Apart from 
its chronic nature, and the degree of suffering 
icaTexpEdo a n nceofphys " involved, the fact that she had been treated by 
several eminent physicians in different parts of 
the country with such a signal want of success, leads one to in- 
quire into the reasons for their failure. The more obvious of 
these reasons evidently was the lack of a correct diagnosis. The 
husband assured me that but one of the doctors had ever proposed 
an examination of this case per vaginam, and that, one was not 
permitted to make it. For this reason, — because they did not 
pursue this investigation as they should have done, — the whole 
corps, embracing distinguished practitioners of both schools, failed 
to bring relief. Indeed my immediate predecessor had told the 
patient's friends that nothing could be of more than temporary 
benefit, and accordingly prescribed the free use of the sulphate 
of morphia, which I found her in the habit of taking ad libitum, 
and in incredible quantities. 

Such an oversight is scarcely excusable upon any grounds what- 
ever. As physicians we should respect the delicacy of the sex, 
and the cautions enjoined and practiced by the profession against 
all unnecessary and unwarrantable officio usness in trivial cases, 
where a manual examination is uncalled for ; but to allow any 
squeamish scruples to be in the way of the patient's recovery, or 
to fancv that constitutional remedies given in the dark, are capa- 
ble of removing a mechanical difficulty of this kind, argues both 
a criminal and a crazy neglect of duty on the part of the doctor. 

It is worthy of remark that by proper means the diagnosis was 



NEURALGIC DYSMENORRHEA. 213 

not difficult, and that the relief afforded by the single introduc> 

tion of this dilator was complete and perma- 

Entire relief through a nen t. I saw my patient three years later, and 

simple operative expedient. J r j 

she had had no return of the difficulty. In this 
operation there was no cutting of the contracted cervical fibres, 
for, as you perceive, this instrument has no edge with which to 
divide them. The mere passage of the smaller sound, and then 
of the larger one, did not accomplish the result, for their use in 
the first instance did not lessen the pain and suffering in the least. 
There were no evidences of existing or of previous inflammation ; 
and if there had been, we can not suppose that so simple and 
transient a means could possibly dispose of them so instantane- 
ously almost, and so entirely. 

This case was evidently one of neuralgia, a pure neurosis, de- 
pendent upon permanent contraction of some of the circular 
fibres of the upper portion of the cervix uteri, 
unaccompanied either by inflammation or its 
consequences, but presenting its symptoms both during the 
monthly flow and also in the interval between the periods. 

In most cases of neuralgic dysmenorrhea, the pain and suffer- 
ing are limited to the monthly return. Any undue determination 
of blood to the uterus, or even a slight delay in 
a ^Sorrhffi^ neural§k ^ ie appearance of the discharge, incidental irri- 
tation or displacement of the organ, or ulcera- 
tion or inflammation thereof, may be the exciting cause of the 
attack. The pain may be limited to the pelvic or the ovarian 
regions, or it may assume the form of neuralgia located elsewhere, 
as in neuralgic headache, neuralgia of the face, the teeth, the 
eyes, the fingers, the toes, the mammae, the intercostal spaces, the 
stomach or bowels, or even of the heart. In such cases the suf- 
fering commonly subsides when the " period " has passed. But, 
exceptionally, as in the case of which I have spoken, where the 
local spasm or irritation of the cervix is perpetuated, the remote 
pain and suffering do not subside, but persist throughout the 
month. You should remember this fact, else the continuance of 
this form of secondary neuralgia may lead you to suppose that it 
has no possible connection with the uterus. 

In those who are predisposed to this form of dysmenorrhcea, 
and who are generally of a neuralgic tendency, the slightest excit- 



214 THE DISEASES OF WOMEN. 

ing causes may induce it. One of my patients, a very observing 
and truthful person, who had had this disease 

Causes of dysmenorrhea. 

tor many years, remarked that when she ate very 
lightly, on the advent of the menses, the suffering was very much 
lessened. Her habit was to diet herself strictly the day before 
the flow came on, and to eat sparingly of light food until it ap- 
peared freely. A hearty meal at the beginning of the period 
would increase the suffering in a ten-fold degree. 

All those habits of mind and body, which induce prostration 
and perturbation of the nervous system, are likely in those who 
are impressionable, to bring on this form of painful menstruation. 
The incidental suffering, as in neuralgia, is always periodic and 
paroxysmal. A predisposition to this peculiar kind of nervous 
derangement, which implicates menstruation and involves great 
suffering, runs in families, and, during the first few years of their 
menstrual and sometimes of their married life, every daughter 
will be the victim of these functional derangements. Not unfre- 
quently the most aggravated cases of neuralgic dysmenorrhea 
occur in the experience of those women whose married life is an 
unhappy one, and who, either from a physical inaptitude for, 
loathing, or an # excess of venery, suffer the evil consequences of 
forcible, frequent or incomplete intercourse. 

When the flow commences, the pain usually remits. And this 

is true however remote its location. But sometimes the relief is 

more direct and positive. Only yesterday a 

th?de a gr° e e of pai^™ t0 lad y tolcl me tliat she always felt light of heart 
and buoyant immediately the flow began, al- 
though but a few minutes before she had been in real agony, and 
was peevish, irritable, and extremely sensitive to any little slight 
or injury. The relief sometimes re-acts in such a way as to bring 
on a hysterical fit of crying or weeping, or of both these together ; 
or it may be followed by tranquil and refreshing sleep. In very 
rare cases it is followed by inordinate sexual desire, amounting to 
temporary nymphomania. 

You will sometimes, but not always, find the distinctive and 

characteristic indications for the remedy in the 

remedSs tIons for internal kind, degree, location, and especial peculiarities 

of the pain, wherever it may be seated. These 

details are so varied, and so insusceptible of classification, that 



SPASMODIC DYSMENORRHEA. 215 

you will be compelled to select from a list of remedies which 
are suited to the cure of every shade and form of neuralgia. 

Acting upon the hint that so slight a cause as the swallowing 
of a teaspoonful or two of cold water may cause a spasm of the 

uterine cervix, with scanty and painful flow, 
w^r™ instead ° f coM m y fri en d' Dr. M. F. Page, has sometimes given 

gelseminum 1, fifteen drops in half a teacupful 
of warm water, one teaspoonful to be taken every five minutes 

until relieved, then less frequently with the 

happiest results. In this form of dysmenor- 
rhcea, at or near the climacteric, he has great confidence in verat- 

rum viridel, five drops in the same quantity of 

Veratrum viride. 

warm water, and the same dose repeated every 
ten or fifteen minutes. Yet, it often happens, that what will re- 
lieve one case will in another case seem to be without effect, even 
where the symptoms are very similar. 

There are some cases of this disease which can be cured most 
promptly and satisfactorily, and without any harmful conse- 
quences, by the use of local means. Careful 

Dilatation. . .-..,., 

dilatation may suffice — as it did with my pa- 
tient — to paralyze and overcome the morbid spasm and hyperaes- 
thesia of the uterine cervix, upon which the whole mischief really 
depends. In neuralgic and spasmodic clysmenorrhcea, I think it 
better to perform this operation with solid than with sponge tents. 
Indeed, in some cases of this kind, I have remarked a singular ag- 
gravation of the suffering from the use of the latter, especially 
when introduced in advance of the flow. 



SPASMODIC DYSMENORRHEA. 

In illustration of the fact that neuralgic and spasmodic dys~ 
nenorrhcea are essentially the same, and that their treatment 
varies chiefly on account of the individual peculiarities of the 
patient, I now present you with the following case : 

Case. — Miss , age twenty-three, has been out of health 

for a year and a half. She first menstruated at fourteen, and 
experienced no unusual difficult}^ until eighteen months ago when 
in advance of the flow, she began to suffer unbearable pains in 
the stomach and over the whole abdomen and extending down 
the limbs. Her only means of relief is in whisky or gin, which 
she takes and goes to bed, and after sleeping two or three hours 



216 THE DISEASES OF WOMEN. 

the pain ceases and does not return until the next period. The 
flow is regular as to time, but with it membranous shreds are 
expelled. She is nervous and excitable, and has slight attacks of 
hysteria at each period, and at these times the least touch of her 
clothing is oppressive to her. Ignatia 3, three times a day. 

Feb. 4. The flow commenced yesterday at twelve o'clock, and 
continued three hours without pain, after this for a few hours 
there was some pain, but less than ever before, and she did not 
take her usual preventive. The flow still continues, she has 
some headache which began with it and which she never had 
before. Continue ignatia 3. 

Feb, 18. She "feels well." Continue the ignatia until the 
flow begins, then let her take gelsemium during the period. 

It often happens that one may learn an important clinical lesson 

from domestic experience. The fact that this girl found relief 

from her painful disorder bv the use of gin or 

a^^^ ttheelnwh{sk y' settles the question as to the form of 
dysmenorrhcea to which she was subject. But 
her experience is of little use to us except in a diagnostic point 
of view. No amount of gin would have cured her, nor have we 
the exact counterpart of either of these stimulants in any of our 
attenuations. The essential hint derived from what she told us 
on her first visit, was that her dysmenorrhcea was local, spasmodic, 
and therefore of a purely nervous character. This temporary 
lesion was engrafted upon the hysterical temperament, and that 
was all there was of it. 

If she was a married woman, and had borne children, the case 

would have been different, for a pure spasm of the cervix which is 

sufficient to obstruct the flow, and which is 

Exceptional hint. . , . 

independent of uterine flexion, is very rare with 
those who have ever been pregnant. Under those circumstances 
a local examination would have been necessary before we could 
have decided upon the nature of the difficulty. 

If this patient had been placed under the influence of opiates, 
anti-spasmodics, or the more fashionable hypnotics, the result 

would have been the same as when she took the 

liffects of opiates etc. . , . 

gin, and the relief would have been transient. 
There is no doubt that, given in this manner, such remedies often 
work mischief. 

The hysterical excitement at the approach of the period, the 
hyperesthesia of the cutaneous surface, and the relief afforded by 



SPASMODIC DYSMENORRHEA. 217 

sleep, furnish the prominent indications for the remedy that was 

given her. The headache that followed was not 

Hysterical indica- d t a medicinal aggravation, although it might 

tions f or ignatia. °° 7 _ o c^ 

have been a consequence of having taken ignatia. 

In cases of a true medicinal aggravation some of the original 

symptoms must be increased in severity; but 

Medicinal aggravations. ' . " 

here we have a new symptom altogether; a 
state of things which does not contra-indicate the continued use of 
the remedy. My own experience has led me to conclude that a 
proper discrimination in this regard is sometimes very important 
in the treatment of the diseases of women. It is not always best 
to stop the use of the remedy directly there are signs of its " taking 
hold." 

My recommendation for gelsemium,to be taken during the flow 
is based upon the observation that it is adapted to overcome any 

disposition on the part of the cervical fibres to 

contract and to cause the flow to intermit, 
which state of things sometimes induces a local spasm of the neck 
of the womb. These are cases of spasmodic dysmenorrhcea for 
the relief of which gelsemium is prompt and effectual. It is 
adapted to hysterical women who suffer severely in anticipation of 
the flow, and who in consequence of a delay, which is not the 
result of a displacement of the womb, of a polypus, or of atresia 
of the cervix — are kept on the verge of spasms, wakeful, restless, 
neuralgic and wretched. The indication is strengthened by the 
occurrence of occasional attacks of ovarian neuralgia, or by a 
morning diarrhoea, and also an hereditary tendency to rheumatism. 
There is quite a list of remedies that have been recommended 
and extolled for the cure of this form of dysmenorrhcea ; but in 

order to prescribe them intelligently, you will 

Other remedies. 

need to search for their special indications in any 
given case. The list includes, aconite, agnus cast., ammonium 
carb., apis mel., atropine, belladonna, cactus grand., cannabis 
ind., caulophyllum, coftea, collinsonia can., macrotin, hamamelis, 
hyoscyamus, lilium tig., moschus, natrum mur., platina, pulsatilla, 
thuja, veratrum alb., viburnum opulus, and xanthoxylum 

Dr. Jousset has often succeeded with magnesia carb. where the 
periods are tardy and where, owing to the pains, the flow is arrested. 

Dr. Richard Hughes says that " When it is rather the uterus 



218 THE DISEASES OF WOMEN. 

which suffers neuralgic pain in the -performance of its monthly 
function, chamomilla and coflea are recommended; and will often 
(the former especially when the temper is much disturbed by the 
suffering) give full satisfaction. Should they not succeed, or 
should the general hyperesthesia calling for either be absent, I 
can commend to you the xanthoxylum frax. I am in the habit of 
giving this medicine in most cases w T here dysmenorrhea co-exists 
with some degree of neuralgia ; and can speak of several cures with 
it. If Dr. Massey's key-note for it, " prolongation of the pain 
down the crural nerve," is confirmed, it would seem to correspond 
to ovarian dysmenorrhea also." 

In some cases galvanism is curative, and in others, hot baths, 
electric baths, and Dr. Chapman's hot- water bags are all that can 
be desired during the' paroxysm. A few cases will be relieved by 
marriage and maternity, but sometimes they fail of effect, or they 
may increase the difficulty. 

In very exceptional cases, when the patient is of an hysterical 
diathesis, and the conditions have prevailed for a 
Battels operation for long time, a neurotic condition may have been 
developed that will not respond to the best med- 
ical and moral treatment that can be applied. In some of these 
cases the dysmenorrhcea is the exciting and relapsing cause of 
neurasthenia, of mental perversion and even of convulsions, in 
which the suffering is wearing and exasperating to the last degree. 
Although it sometimes fails, this neurotic condition is often cured 
by a resort to oophorectomy, or the removal of the ovaries and the 
oviducts. I shall speak of the special indications for this opera- 
tion at another time. 



LECTUEE XIII. 



MEMBRANOUS DYSMENORRHEA. 



Membranous Dysmenorrhoe a. Case— Causes, anatomical peculiarities of the Membrane, 
its clinical confirmation. Shape and size of the Membrane. Its expulsion practical 
deductions. Diagnosis from Abortion. Special Therapeutics. Other expedients. 
The sponge tent. 

I will invite your attention this morning to the following- re- 
markable case, which is reported by the patient herself : 

Case. — I was born in July, 1834, in C , Ohio. Soon after 

my birth an eruption made its appearance on the skin, resembling 
rash, occasioned, it was then thought, by the extreme heat of the 
season. I passed the usual diseases of children very early in life, 
and, with the exception of this eruption, which appeared almost 
every year during the summer months, and generally upon the 
lower parts of my limbs, I was a vigorous, active child, full of life 
and spirit, and in apparent perfect health. At the age of fourteen 
years and five months the menses made their appearance. The 
first discharge was plentiful, but attended with no pains or incon- 
venience whatever. One year after they were suppressed about 
three months — caused by thin shoes, wet feet, and not early 
acquainting my mother with the fact. I was soon set right with 
" Cooper's pills." I felt well during the suppression. At sixteen, 
while at boarding-school, my appetite grew voracious, and I ate 
immoderately of all kinds of food, pickles, and sweetmeats. The 
rash had somewhat lessened in its appearance each summer as I 
grew older. It was, however, upon my body one day when, just 
after dinner, in passing through a hall to which the outer doors 
were open, I met a furious gust of wind from an approaching 
thunder-storm. At the moment I noticed no uncomfortable sen- 
sation, but was shortly seized with great difficulty of respiration 
and extreme prostration, and in less than an hour my life seemed 
hopeless to those around me. This was the first attack of any- 
thing like illness since my babyhood. Two physicians were 
speedily called, who said, " the rash had suddenly struck inward." 
Two days before this I remember to have been very nervous, so 

219 



220 THE DISEASES OF WOMEN. 

• 

that I could not go to sleep on retiring, but did not know that 
anything ailed me. The doctors gave me tumblers full of a mixt- 
ure of asafcetida ; valerian was also given. I do not know what 
else was administered, as I was only partially conscious. My suf- 
fering was almost wholly from the gasping and struggles for 
breath. The rash never made its appearance again until I was 
thirty -four years old. I was left weak and sick (J think, from the 
effect of the dosing). It was one or two days before I could be 
removed home. Very soon my monthly period came on, attended 
with some pain. My mother told the physician, and he gave me 
hyoscyamus. My school days ended with my first illness. I was 
never able to return to school-life again. The remainder of that 
summer I was weak, and very nervous frequently ; had severe 
palpitation of the heart, and often could scarcely control my limbs 
and face from twitching violently, which they sometimes did in 
spite of me. The physicians prescribed for " nervous paroxysms," 
" constipation," and " general debility." I took quantities of the 
different preparations of iron and nervines. One medicine was to 
be dropped, " eighty drops every two or three hours." I knew 
nothing of modern glass-drop measures, and went entirely through 
the "dropping " ordered each time as prescribed. During the fol- 
lowing eighteen months dyspepsia and nervousness were my prom- 
inent troubles ; also obstinate constipation, occasionally having 
some pain at my menstrual periods, which grew somewhat irregu- 
lar ; but I entered into the usual duties of life, and passed for 
being in pretty good health. 

I was married at eighteen. After marriage, nothing about my 
menstrual periods attracted my attention for three months, when 
I passed over seven weeks without them. My form grew some- 
what fuller, and I craved certain articles of food. I took " Coop- 
er's pills" at m} r own instigation. When the discharge made its 
appearance it was attended with great pain, so that I was obliged 
to go to bed. I felt very sick, and a physician was called — one 
whom I had never seen. He gave me soothing medicine, but 
never said what ailed me. He attended me several months, but 
never inquired about anything but my constipated habit, and the 
nervous condition of my system. The following monthly period 
I was able to keep out of bed by taking spirits of camphor, which 
he gave me, very often through the day. During that year I had 
severe nervous paroxysms, violent jerking of the limbs and body, 
especially at night. In a few months I suffered extremely with 
every menstrual period the first twelve or twenty-four hours. 

I then went to C , to the care of the physician who had 

attended at my birth, and had known me all my life. He was the 
first who made vaginal examination. He reported a partial " retro- 
version of the uterus," and said I had " ovarian tumor." I went 



MEMBKANOUS DYSMENOKKHCEA. 221 

through a long series of blisters on my spine and abdomen, purga- 
tives, etc. I was in his care more than a year. As I could not 
live in the city, I was not constantly with him. I never could 
myself discover the slightest soreness or enlargement in the ova- 
rian region, and wondered that I could find no evidence of the 
tumor. About this time I began suffering with what seemed to 
be rheumatism in my right limb, particularly when on my feet, or 
standing much. I rarely ever had it when warm or in a reclining 
posture. 

In a year or more I grew weary of going into C , of blister- 
ing and doctoring, and did without professional aid for a year or 
two. I did better without it than with it, as my general health 
was better. About this time, I once took chloroform to have a 
tooth extracted. It was with great difficulty that I was revived 
from its effects, and for sixteen hours I kept constantly sinking 
away. 

I next went to R , to a physician. He found " the uterus 

hardened at the neck and too low in the vagina." He first gave 
me a violent emetic, used electricity, had my whole body daily 
rubbed with No. 6, and like stimulating liniments, and put a 
Banning's body brace upon me. I took a great deal of macrotin, 
tonics, etc. His treatment, which continued several months, 
improved my general health more than any I had had. Yet my 
menstrual flow did not come right. Finally, he one day ran his 
fingers violently through his hair, and said "he could not see 
what did ail me." 

I went home discouraged, and again did without medical aid 
for two years more. Indigestion, cold feet, rheumatism, attended 
Vy the whole train of disorders of the nervous system, had been, 
ond was, my constant experience. I rarely ever had any pain in 
my head or spine, after the first year of my married life. A nat- 
urally gay temperament, a great love of fun, horseback riding (of 
which I was very fond), carriage driving, travel a part of every 
year, with never any very laborious household duties, probably 
kept me from becoming a bedridden invalid. 

On removal into the city of C I again sought professional 

treatment. I had then been married six years. Faithful adher- 
ence was made to injections of rose-leaf tea, and numerous other 
local remedies, and a gold pessary was introduced. Finally, after 
nearly two years of constant treatment, it was satisfactorily dis- 
covered that I had " rheumatism of the womb." I was under 
the care of this physician for six years, and took a great deal of 
medicine — I think considerable quantities of gum guaiacum in 
brandy. 

The year of 1865 I traveled in Europe, and some in our own 
country. I have always borne travel well, enjoyed it thoroughly, 



222 THE DISEASES OF WOMEN. 

and fellow-travelers seldom have discovered that I was not in 
health. 

In February, 1868, I removed to Chicago. The cutting winds 
affected me so that in less than three weeks I dreaded to go out 
of doors — they seemed to search my very bones. A thirst which 
could not be satisfied soon set in, and, shortly, a retention of 
urine, with rheumatism in my whole right side. I was very sleep- 
less. The atmosphere seemed too cold for me to breathe, and I 
was obliged to cover both head and ears to get sleep at all. I 
found temporary relief in short, repeated visits to Cincinnati and 
Springfield,- Illinois. In May I had several large carbuncles, 
during which my indigestion and other difficulties were much 
relieved. About this time I frequently felt sharp pains about my 
heart, and sometimes a sense of dizziness, which soon left me if 
I laid down for five minutes. I often would catch my breath in 
going about in common employments, and drew long, deep sighs 
in ray sleep. I was nervous and wretched — and the monthly 
period was attended with increased suffering. 

In July I went to the sea shore, as had been my custom for 
several years, and from which I had always returned in much 
more comfortable health. The weather during the journey was 
exceedingly hot, the warmest known for years. On reaching 
Philadelphia by a morning train, with scarcely a dry thread upon 
me from perspiration, I found my body covered with rash or 
prickly heat, which I had not seen for eighteen years. It did not 
wholly disappear at once. I had passed through the catamenial 
period just before leaving home. We reached the sea-side, and 
the sea-breeze was, as usual, invigorating and refreshing to me. 
I bathed for one week. I was very fond of swimming, but found 
the exercise too severe for me, and, this time, could not practice 
it at all. On retiring one night I found a steady pain in my left 
breast. I took little notice of it, supposing it to be caused by 
indigestion, or pleurisy. It often awakened me during the night, 
but by putting my hand on the spot and warming it, I dropped 
to sleep. Next morning I folded a flannel several thicknesses 
and put over it, dressed, and ate my breakfast, as usual. Soon 
after breakfast I was seized with the pain most violently, and 
seemingly in the region of the heart. In ten minutes I was pros- 
trate. A mustard plaster applied increased my suffering fearfully. 
Dr. B., of Philadelphia, was summoned, and a young physician 
was present. Dr. B. at once pronounced the attack " rheumatism 
of the heart." The pain once suddenly went to the bladder, 
causing excruciating agony. A very copious discharge of urine 
soon followed, and the distress was again in the heart. I was 
relieved by aconite. In two weeks, at Dr. B.'s urgent advice, I 
was taken to Capon Springs, Hampshire county, Virginia. This 



MEMBRANOUS DYSMENORRHEA. 223 

spring is celebrated for its use in " the different forms of dyspep- 
sia, and as a remedy in gravel its virtues are said to be unques- 
tionable - 1 while externally applied in the shape of cold or warm 
baths, its results " are proved beneficial in rheumatism and diseases 
of the skin." I spent three weeks here, and my heart was 
entirely relieved ; but, after leaving, I was again attacked, in 
about a week, in the city of Brooklyn. The medical attendant 
there never said what he thought my disease was, but " supposed 
my trouble proceeded from the spine." He was positive there 
was no disease of the heart. 

All the physicians said I must not return to the climate of 

Chicago, so I went to my relatives in the west, to R , where 

I was attended by a physician two months. There was a great 
deal of soreness to the touch about my heart, with constant, 
severe pain, and I could not endure a breath of outside atmos- 
phere, though it was only the first of October. He said I had 
"angina pectoris," and u h}"dro-pericardium." I had noticed I 
suffered more with my heart about the time the menses made 
their appearance — generally a few hours before, and I asked him 
to find whether there was not something wrong in connection 
with the uterus, as I had had no attention to that organ for five 
years. He made examination and told me I " was all right 
there." 

Suppose we recapitulate the chief points in this case, which our 
patient has detailed in so interesting and truthful a manner. Her 
first menstruation was prompt, plentiful and painless. One year 
later, amenorrhcea (suppressio mensium), from cold and wet feet. 
At sixteen inordinate appetite, the rash declining — -sudden and 
severe illness from repercussion of the eruption, which did not 
reappear for many years — inveterate and inexplicable nervous 
symptoms. After marriage, at eighteen, menstruation normal for 
three months — then seven weeks' interruption — " female pills" 

— illness. After this, painful menstruation each month — another 
physician, diagnosis of retroversion with ovarian tumor — blisters 

— purgatives, etc., for a year — apparent rheumatism in the right 
limb, worse on standing, relieved by warmth and rest in the 
reclining posture — was a confirmed invalid at twenty, but dis- 
abled only for the first few hours of the " period" — abandoned 
all treatment for a }~ear or two, and improved in consequence — 
another doctor ; diagnosis, induration of the cervix and prolapsus 

— emetics, electricity, friction, an abdominal harness, macrotin 
tonics, etc., — improvement of general health, but the menstrual 



224 THE DISEASES OF WOMEN. 

disorder unchanged — the doctor at his wits' end — abandoned all 
treatment for two years more — nervous disorders continue — still 
another physician — two years treatment and a diagnosis of 
44 rheumatism of the womb" — continue treatment four years 
more (six in all) — with a faithful trial of Dewees' prescription 
of guaiacum — 1865 in Europe- — 1868 removed to Chicago— - 
prairie winds in spring unfavorable — critical and salutary boils 

— increased cardiac trouble — rheumatism of right side — monthly 
symptoms worse — goes to the sea-shore in July — after a copious 
perspiration the eruption, which had not been seen for eighteen 
years, makes its appearance — cardiac paroxysms at night and 
next day — alternation of rheumatic pain in the heart and bladder 

— relief from aconite — the mineral springs improve the heart 
symptoms — one more doctor and another diagnosis. 

The additional particulars, of clinical interest, which were given 
me when I took charge of this case, are the following : 

About five months after her marriage she commenced passing 
membranous shreds, and since then has never escaped more than 
two consecutive "periods" without them. The size and firmness 
of the shreds vary at different times, but they are not larger, nor 
is the suffering relatively greater at the next period, after passing 
one month without them. The degree of pain and discomfort 
vary with the presence or absence of the membrane, and also 
with the amount of exercise taken at the time the flow commences. 
If she lies in bed for a day or so, there is little relative suffering. 
Although she had frequently spoken to her physicians of these 
membranes, only one had concerned himself about them, and he 
had decided, in an off-hand way, that they were the result of a 
miscarriage. None of them ever made any inquiry with respect 
to the character of these products, and until I procured this first 
specimen for microscopical examination, no one, except the patient 
and her husband, had ever seen them. 

Upon careful inquiry, I learned that she suffered at times,, 
usually some hours in advance of the flow, from a circumscribed 
pain in the right ovarian region. She could cover the spot with 
the tips of her three fingers. The pain would radiate somewhat, 
and extend thence along the limb. It was invariably worse in 
damp weather and after exercise. 

While the cardiac symptoms were more or less constant, they 
were greatly aggravated at the month. Indeed, her sufferings at 
this time were extreme and alarming. She had discovered that 
aconite 2nd would relieve this distress in a very few minutes, 
but disliked to take it on account of unpleasant symptoms, which 



MEMBRANOUS DYSMENORRHEA. 225 

almost invariably followed some hours after. The chest had been 
most carefully wrapped in flannels. The slightest change in her 
clothing or exposure resulted in her taking cold and in an increase 
of suffering. Daily and prolonged friction, with stimulating lini- 
ments, had been resorted to in order to keep the blood in motion. 
The spine was exceedingly sensitive to pressure throughout its 
whole extent, for the relief of which porous plasters had been 
worn almost constantly for months. 

I found the uterus so prolapsed that, unless it was supported 
by a sponge, pessary or tampon, which she had worn habitually 
for years past, she could not stand or walk. With this deviation 
of the womb there was more or less of strangury, which at times 
annoyed her exceedingly. She has never borne any children. 

This case presents some striking practical facts. It illustrates 
that one physician, and sometimes a number of them in turn, may 
be deceived concerning the nature of the disease which they have 
been called upon to treat. It shows how the reflex and secondary 
phenomena dependent upon uterine disorder may mislead the 
practitioner ; and how apt the most experienced in our ranks are 
to overlook the most important symptoms, while at the same time 
they put great stress and emphasis upon such as are merely 
incidental. 

Membranous dysmenorrhea is a rare affection, and, when it 
does exist, is very apt, as in this case, to have continued for some 
years before being recognized. In exceptional 
lo^ke? _may be ° ver " cases, it occurs in young girls, but is usually 
met with in married women. In the majority 
of instances it begins soon after marriage, when it is accompanied 
by such slight symptoms as to be deemed of little consequence. 
Under these circumstances, it is usually regarded as the sequence 
of an early abortion. 

We have to confess that the special pathology of this disease is 

not very well known. Dewees and others have taught that it 

occurs most frequently in women of a rheu- 

Causes. . . . 

matic diathesis. Some authorities insist that 
the membranous formation, which is its chief characteristic, is 
always the product of conception. But this cannot be true, for it 
may occur in the virgin, and also in those who have for many 
months abstained from sexual intercourse. It is the commonly 
received opinion that, while in its beginning it may date from a 



22 15 THE DISEASES OF WOMEN. 

miscarriage, the continuance of the complaint is not necessarily 
connected with conception. 

Others hold that the membranous product results from uterine 
inflammation. Upon this theory a recent author proposes to style 
the disease " endometritis epithelialis." But it is not of the exfo- 
liation of the epithelium merely that we are speaking. That may, 
and often does, occur in healthy menstruation. Oldham and Tilt 
refer the exfoliation of this membrane to the morbid influence 
exerted upon the lining membrane of the womb by disease of one 
or both of the ovaries. In rare instances, it may originate in 
syphilis. Sometimes it is related to a cutaneous eruption which 
has been repelled from the surface, with the appearance of which 
its symptoms seem to alternate. 

Here are two excellent specimens of the membrane which this 
patient has expelled with the menstrual flow. Let us examine, 
into its anatomical peculiarities. The old au 
onhem?mbrane Culiarities tnors thought it to be a kind of croupous 
deposit upon the uterine surface. They talked 
wisely, as some surgeons do in our day, of the spontaneous organ- 
ization of coagulable lymph into a pseudo-membrane. Dewees 
even suggested that these membranes might be formed from the 
lymph contained in the menstrual blood. 

If we compare this membrane with the decidua vera in the 
early weeks of pregnancy, we shall discover an exact correspond- 
ence. It is triangular, smooth within, and 
identical with decidua roil or]i and villous on the outer surface. If the 

vera. o 

entire cast has come away, or if we can place 
the shreds together properly, we shall find the three orifices cor- 
responding with the internal extremities of the Fallopian tubes, 
and the os internum of the uterine cervix. Moreover, here are 
numerous little openings through which the utricular glands have 
discharged their product. The microscope proves these mem- 
branes to be identical in structure. And their histological elements 
are precisely the same as those of the uterine mucous membrane 
also. 

It is undoubtedly true, therefore, that the decidua menstrualis, 
as Virchow named it, is not a new or heterologous membrane 
which is formed and expelled the womb at each menstrual period, 
but the altered lining of that cavity, which has been cast off by 
a species of physiological moulting. 



MENBRANOUS DYSMENORRHEA 227 

Kow, inflammation is not a factor in the organization of the 

deciclua menstrualis, any more than in that of 

,den n taf mmation ' s acci ~ tne decidua vera, or the outer envelop of the 

embryo. It is, indeed, incidental to both these 

processes, but it is not necessary to either of them. 

There is, therefore, something plausible in the theory of Old- 
ham, that ovarian influence has much to do with the frequent 
exfoliation of the uterine mucous membrane in 
oidham's theory of ova- ^his c i ass f subiects. In case of conception, 

nan influence J i - 

this influence undoubtedly initiates those 
changes which finally develop the decidua vera before the fecun- 
dated ovum has dropped into the uterine cavity. And do you not 
perceive that a slight perversion of function in the ovaries may 
induce a similar physiological change in the uterine textures as a 
contingent of menstruation? In the former case, the egg is 
retained throughout the period of gestation, and finally extruded 
at term. In the latter, it must escape, with its accompanying flow, 
as soon as practicable. In both, the deciduous wrapper is sooner 
or later expelled. 

This view has its confirmation in such clinical facts as the fol- 
lowing : When the " period " sets in, the ovaries are often found 

to be swollen, tender, and the seat of discom- 

Its clinical confirmation. _ . 

tort. In a majority ot cases there is considera- 
ble pain in one ovarian region (usually the left), which persists 
until after the escape of the flow, and of the shreds also. Grailly 
Hewitt is quite emphatic on this point and its significance :* 
" There is often pain in one or other ovarian region ; and it ap- 
pears reasonable to conclude that in some way or other this pain 
is connected with the formation of the membrane. The intimate 
functional relation between the ovaries and the uterus lends sup- 
port to the view that in a morbid condition of the ovary — a 
functional perversion, so to speak, of its influence over the uterus 
— we have an explanation of this abnormal occurrence." 

The single pathognomonic symptom of this disease is the dis- 
charge at the menstrual period of such a membrane as is shown 

you in this specimen. Sometimes, although 

Clinical history. . . r 

rarely, it comes away in the form of a sac, or 
complete cast of the uterine cavity, in which case it may be mis- 

* The Diagnosis and Treatment of Diseases of Women ; London, 1863 ; p. 479. 



228 THE DISEASES OF WOMEN. 

taken for a mole. Usually, however, it is in shreds and pieces T 
which vary in size from that of your thumb nail 
m?mbrane and size of the to two or three square inches. These pieces, 
may be so regularly formed that } r ou can place 
them together in such a manner as to be certain from the triangu- 
lar shape of the mass, as well as from other characteristics, that 
the womb has been stripped of its lining membrane throughout. 
In some cases a very considerable quantity of this menstrual 
decidua is thrown of. 

It may happen that this membrane will be seen but once in the 
same patient. Or it may be observed each month regularly in 
others. Sometimes it appears at alternate 
an?e Sularity ° f ks appear " mon ths, and again only once in three months. 
In the case which I have just detailed, my 
patient did not for many years pass more than two consecutive 
"periods" without their being present. And this under every 
variety of climate and external circumstance. 

The subjective symptoms vary in different cases. Beginning 
usually with a delay in the appearance of the accustomed men- 
strual flow, the suffering is analogous to that in 

Its expulsion. . ..,,■. 

an early abortus, and in other varieties 01 dys- 
menorrhea. Subsequently it will be modified by the condition 
and susceptibility of the patient, as well as by the size of the 
membrane to be extruded, and the ease of dilatation of the cervi- 
cal canal through which it must pass. Some women suffer as 
severely as they would in labor at term. As I have already said, 
the ovarian pain is seldom lacking. One of my patients finds her 
suffering greatly mitigated by lying in bed for one or two days 
when the " period " arrives. And the patient whose case is under 
review has remarked that, when she ate very lightly, the men- 
strual suffering was very much lessened. In her experience, a 
hasty meal taken immediately before the catamenial flow occasions 
extreme suffering. Scanzoni reports that two of his patients 
" could always say, with perfect certainty, one or two weeks be- 
fore the return of the courses, whether or not they would pass 
membranes. Every time that this was the case they experienced 
for one or two weeks previously, a sharp, pinching pain in the 
umbilical region." 

The quantity of blood discharged in such cases is in excess of 



MEMBRANOUS DYSMENORRHEA. 229 

that proper to health}' menstruation. This can be readily explained 
as the consequence of detaching the lining 

The "flow' proper „ , , „ , 

membrane ot the womb trom a sub-mucous sur- 
face which is unusually vascular. It corresponds in every way 
with the haemorrhage incident to abortion prior to the formation 
of the placenta. Sometimes the flow is profuse and alarming, but 
as a rule it is held in check by the contractile efforts of the womb 
to dislodge and expel the membrane. When this has escaped, it 
usually, but not always, ceases. Where some small shreds are 
retained, there is danger of subsequent loss of blood. In women 
•of an haemorrhagic diathesis, the flow may degenerate into a pass- 
ive haemorrhage and continue during the inter-menstrual period. 
In case the decidua menstrualis is not cast off, but remains until 
the next month, as sometimes happens, the flow may be scanty in 
amount at one period and copious at another. 

The reflex nervous symptoms which are present in this form of 
dysmenorrhcea vary in different persons. In some the stomach is 
the focal point of disorder, and a most intracta- 
ble vomiting results. Our patient has suffered 
from this symptom for nearly a fortnight at a time. In others, the 
greatest care is requisite to avoid severe fits of indigestion. A 
majority of these patients are habitually costive. 

If she is of a rheumatic diathesis, the cardiac s} r mptoms may be 

so pronounced and so clamorous as to lead to the belief that the 

heart is the real seat of the difficulty. It was 

Reflex cardiac symptoms. . . 

this state of things which induced my prede- 
cessors in the management of Mrs. 's case to form an incor- 

xeet diagnosis. In the frequent recurrence and severity of her 
paroxysms of dyspnoea, the palpitation, cardiac pain, oppression 
and perturbation, there were evidences of functional derangement, 
but of nothing more serious. The doctors must have drawn on 
their imagination for the physical signs of organic disease of the 
heart. At least, I have examined her repeatedly, and most care- 
fully, without being able to discover any lesion of the valves, of 
the pericardium, the endocardium, or of the parietes of the heart. 
Moreover, as soon as she was put upon the remedy which was ap- 
propriate for the relief of the menstrual disorder, the cardiac 
symptoms vanished. 

You should bear in mind that the remote symptomatic affections 



230 THE DISEASES OF WOMEN. 

of the heart, and of other organs, which are dependent uport 
uterine disease of whatever variety, are invaria- 

Practical deductions. J 

bly aggravated at the month. Indeed, in most 
cases, they intermit and return as regularly as the menses them- 
selves. Independently, therefore, of the presence of the decidua 
menstrualis, this one circumstance would have led any one of you 
to infer that in this case the heart symptoms were reflex, and not 
idiopathic. It is true, however, that organic disease of the heart 
may finally result from such an indirect cause, when that cause i& 
in almost constant operation for many years. But such cases are 
exceptional. 

As in other forms of dysmenorrhoea so in this, uterine displace- 
ments, more especially prolapsus and retroversion, are very apt to 
result. In some cases the most obstinate and 
tio^r sequentuterineaffec ~ distressing anteversion has been caused by mem- 
branous dysmenorrhoea. Either and all of these 
deviations increase the difficulty and embarrass the treatment. 
Fibroids, polypi, metro-peritonitis, endo-metritis, and endo-cervic- 
itis, are also coincident diseases. 

You would diagnosticate a case of membranous dysmenorrhoea 
from one of abortion, by the regular return of the monthly period, 
by the membrane usually coming away in 
t . Diagnosis -from abor- s h rec ls, or if it were entire, by the sac contain- 
ing no rudiment of an embryo or of other mem- 
branes enclosed within it, and by the perforated, sieve-like appear- 
ance of the membrane itself. These symptoms, however, are not 
positive, for the patient might abort exactly at the first month ; 
or, because the ovum is sometimes dissolved, the sac might be 
empty. But it would be quite extraordinary and unprecedented 
for one to abort each month regularly. 

The only danger is from concomitant disorders. The patient 
might possibly die from hsemorrhage, but that would be very rare. 
A continuous and copious loss of blood might 
so undermine the general health as ultimately 
to endanger life. Or real organic disease of the heart, lungs or 
stomach, or even of the brain or spinal cord, might finally develop 
and destroy it. In the case of patients who are approaching the 
climacteric, your diagnosis should be guarded. It is very proba- 
ble that, could they be seen at an early date in the history of the- 



MEMBRANOUS DYSMENOltllHCEA. 231 

disease, most cases would be curable. Sterility is an inevitable, 
but not always an incurable, consequence of membranous dysmen- 
orrhcea. 

Treatment. — The proper management of this disease will draw 
largely on your skill, your professional knowledge and experi- 
ence, your tact, your deliberation, and your 

General therapeutics. _,_ M1 , . , ,, , . 

patience. You will have to consider the modi- 
fying influences of the rheumatic diathesis, of the abortive ten- 
dency, the ovarian -disease, the repelled eruption, the reflex com- 
plications, and even of secondary disease in the uterus itself. 
There is no specific treatment which is suited to all cases of mem- 
branous dysmenorrhea alike. An exclusive idea of its therapeu- 
tics would certainly mislead you. 

Some cases of this disease are undoubtedly rheumatic, while 
others are not. The susceptibility of our patient to the damp, 

chilling prairie winds in the spring, the fugitive 

pains in her chest and right limb, the cardiac 
s}^mptoms, and the relief afforded to all these by removal to a 
milder and more equable climate, betray the rheumatic complica- 
tion. These and similar symptoms in one who was predisposed to 

rheumatism, would suggest such remedies as 
tions r rheumatic c ° mpHca acon ite, bryonia, rhus tox., nux vomica, mercu- 

rius and macrotin. Care should also be taken 
to protect the patient against the harmful influence of exposure to 
storms, or sudden and extreme vicissitudes of weather. She 
should be warmly clad, and in a measure insulated by flannel or 
silk wrappings. Above all things, the night air is especially inju- 
rious to this class of subjects. 

In a few women, the tendency to a periodical exfoliation of the 
uterine mucous membrane constitutes a species of dyscrasia. If 

these persons conceive, they are very likely to 

For the abortive dyscrasia. , -i • o ,1 -i , i 

abort; and 11 they do not become pregnant, 
they are fit subjects for the disease in question. This abortive 
habit is a powerful predisponent of membranous dysmenorrhcea. 
Most of the hints which are applicable to the prevention of threat- 
ened abortion are equally appropriate here. I need not pause to 
detail them. 

It may happen, in exceptional cases, that the character and his- 
tory of a repelled eruption will point out the proper remedy. 



232 THE DISEASES OF AVOMEN. 

When this patient placed herself in charge of her last physician, 
she was put upon sulphur 30th, with prompt 
tiQ in .case of repelled erup- an( i evident relief of all her symptoms. This 
was prescribed on account of the chronic nature 
of her disease, and its manifest relation to the eruption which ha(l 
been repelled. A few doses of apis mellifica 3d were then given 
for the ovarian pains, the urinary trouble and the cardiac symp- 
toms, and she was finally ordered calcarea carbonica 12th, which 
she is now taking. 

In so far as the reflex symptoms are concerned, there are but 
very few of them that are distinctive, sugges- 
va Reflex symptoms irreie- fty^ or reliable. They are quite too sensa- 
tional to be trustworthy. You cannot depend 
upon them as indicating the suitable remedy, any more than upon 
a majority of similar symptoms in hysteria. 

The ovarian lesion and its symptoms are more significant. For, 
in most cases, if we can recognize and remove 
toms r the ovarian symp ' them, we may hope to cure the menstrual dis- 
order. Apis mellifica, calcarea carbonica, pla- 
tina, belladonna, colocynth, lachesis, thuja, kali jodatum, mercu- 
rius, or hamamelis, may be appropriately and successfully em- 
ployed. 

Since we understand the origin and structure of the decidua 
menstrualis, the stereotyped advice to employ such remedies for 
the cure of this disease as are given in pseudo- 
^ An antiquated prescrip- membranous croup and diphtheria, would be of 
very doubtful service. For other reasons than 
those usually given, it is possible that in some cases the bichro- 
mate of potassa, mercurius jodatus, cantharis, ammonium caus- 
ticum, or even the chloride of lime, might prove serviceable. In 
a case of this disease, Dr. Mandl,*, however, applied the kali 
chlor. directly to the uterine mucous membrane, at short intervals, 
for the space of ten months. The effect was to interrupt the for- 
mation of the decidual product while he continued the applica- 
tion, but as soon as he desisted, it was formed and expelled as 
before. 

There is no evidence that local applications to the uterine sur- 

* Wiener Med. Wochenschrift, No I, 1869. 



MEMBRANOUS DYSMENORRHEA. 233 

face have ever accomplished any more in this disease than in the 

case just cited. The good they do is temporary, 

Local applications are of anc [ even ^g j g more than counterbalanced by 

temporary benent. «/ 

the risk attending their application ; for you 
may take all the precautions prescribed, and yet, as a rule, they 
are not safe or advisable. 

Marriage has sometimes been prescribed as a remedy for this 
disease, but it is an unwarrantable expedient, and is very likely to 

aggravate the complaint. Conception may cure 

Other expedients. . . - ' _ 

it, provided the patient can go to term. It may 
be indispensable to the cure that she should live absque marito. 
Or we may prescribe that intercourse shall take place only at long- 
intervals. 

Very decided benefit may sometimes be derived from the em- 
ployment of the sponge-tent, with a view to dilate and remove 
any obstruction of the cervix which prevents the 
free escape of the menstrual blood. This would 
cause the womb to disgorge, unload its capillaries, relieve the 
hyperemia, avert an excessive hypertrophy of the mucous mem- 
brane, and possibly prevent its exfoliation. Moreover — and it is 
by no means an inconsiderable thing — this dilatation greatly mit- 
igates the sufferings of the patient. I applied the tent repeatedly, 
and with excellent effect, in the case of which I have now spoken 
to you at such considerable length. 

[One of the most interesting cases in the woman's clinic was No. 
17,027. The patient came to us with psoriasis 

Psoriasis and memb. ... , ,-, ,. -. . ,-. -• 

dysmenorrhea. guttata, the eruption being on the arms and 
chest. For five months it had alternated with 
the expulsion of membranous shreds and clots. The menstrual 
obstruction was accompanied with labor-like pains and suffering, 
which continued for several days, during which time the cutaneous 
eruption disappeared. She first took arsenicum 3, and after- 
wards the 30th, with excellent effect. The irritation of the skin 
was relieved and cured by dulcamara 3.] 



LECTUEE XIV. 

MEMBKANOUS DYSMENORRHCE 1 — CONCLUDED. 

Membranous dysmenorrhea arising from repelled eruptions, from the repercussion or 
cutaneous eruptions; cases; sterility as a sequel ; statistics; result of treatment, etc. 

In July 1876 I had the honor of reading an essay upon this sub- 
ject before the International Homoeopathic Congress which had 
convened in the city of Philadelphia. The views expressed in that 
paper have been confirmed by my subsequent experience, and I 
venture to give you the substance of that report this morning. 

Not the least curious and wonderful of all the physiological 
processes known to us is the periodical development of the 
lining membrane of the uterus. This process of 
"nidation," or nest-making, is as essential a 
factor in menstruation as it is in generation. If it occurred only 
once ill a year, as in the oestruation of animals, it would still be 
remarkable for its delicacy, and for the peculiar contingencies with 
which it is beset. But, in woman, its monthly repetition multi- 
plies the risk of its becoming disordered, and there are compara- 
tively few r who pass through the whole period of menstrual life 
without suffering some of these consequences. 

Membranous dysmenorrhcea is not so well understood, nor so 
skillfully and successfully treated as other kinds of painful men- 
struation. This fact is partly due to its relative 
comparative infre- i n f re q UenC y # p r, compared with the spasmodic 
and obstructive varieties it bears about the same 
proportion that cases of breech presentation do to those of the 
cephalic extremity. 

Now that the shreds, or casts, thrown off in this disease are 
known to be caused by the exfoliation of hypertrophied mucous 
membrane of the uterus, and not by the exudation of lymph, and 
the formation of a new or croupal membrane, its morbid anatomy 
is very much simplified. And the fact that this product is decidual 



MEMBRANOUS DYSMENORRHEA. 235 

and not diphtheritic, homologous and not heterologous, is destined 
greatly to modify its special therapeutics. 

But, however great the advance that has already been made, the 

etiology of membranous dysmenorrhoea is incomplete. For, 

although the felt-like shreds, or strips, which 

Non-inflammatory. ,.,. . ... ,, . , 

are moulted in this disease are recognized as 
portions of the menstrual, or nidal decidua, it still seems practi- 
cally impossible for physicians to separate in their minds the for- 
mation of this product from the existence of the inflammatory 
process. The most recent author even proposes to style it an 
epithelial endometritis (endometritis exfoliative).* On the one 
hand he declares that the sieve-like casts and pieces, consist of the 
hyper trophied mucous membrane which, from the rapid produc- 
tion of free cells, is detached and thrown off at stated periods; on 
the other, that the process is inflammatory and exudative, and not 
a mere exfoliation. Experience proves, however, that while a 
woman with membranous dysmenorrhoea may also have endometri- 
tis, she is quite as likely to have ovaritis, or even endocarditis as a 
coincident affection. 

Accepting the view of Oldham and others that the cause of this 
disease may frequently be found in ovarian irritation and inflam- 
mation ; the idea of Dewees that the rheumatic 

A variety of causes. ....... . . . ,. 

diathesis is responsible tor its existence m a. 
certain proportion of cases; and the more modern claim that it 
may be caused by uterine deviations, my experience leads me to 
conclude that there are some examples of this affection which are 
inexplicable and incurable by, or through, either or all of these 
different theories. In other words, these theories do not apply to 
all cases indiscriminately. 

The most intractable cases of this singular affection that have 
come to my knowledge have been associated in their clinical his- 
tory with the existence and sudden disappearance 
erI r p °tSn C s Utane0US of a cutaneous eruption. This eruption may, 
indeed, have been slight and possibly have been 
forgotten by the patient herself. It ma}' also vary in its character 
in different persons, being either papular, herpetic or vesicular, 
squamous, syphilitic, or erysipelatous. In one of my cases it was 
a " rash, like prickly heat;" in another, the patient was positive 

*Dr. Beig-el, in the Archiv. fur Oynakoh, Band ix. Heft I. 



236 THE DISEASES OF WOMEN. 

that she had once had the " hives," and that her menstrual diffi- 
culty followed directly upon their being- " driven in." 

Sometimes the appearance of this eruption upon the face, hands, or 
body, alternates with the menstrual disorder; but more frequently, 
unless medicines have been taken to " drive it out," no trace of it 
can be found at any time. In one case of erysipelas of the legs 
and thighs the lesion extended to the genitals, and to the womb, 
and a membranous dysmenorrhcea of six years standing was the 
direct result. 

In one of my patients, who was very ill with this form of 

dysmenorrhcea, the repercussed eruption had not been seen for 

eighteen years until it blossomed out as the 

Case. • 

result of my treatment; and I have recently 
cured another in whose case the " salt rheum " had disappeared 
twelve years before, with the immediate advent of shreds and bits 
of membrane in the monthly discharge. 

The comparative frequency of cases of this kind, which have been 
more or less intimately associated with skin affections, precludes 
the possibility of their accidental relation. For, 
out of twelve cases of real membranous dysmen- 
orrhcea which I have treated within the last five years (1876), eight 
of them have been of this sort. In this list I do not include those 
milder cases which are very much more numerous, and in which 
there is merely an increased desquamation of the uterine epithelium 
in the form of diaphanous shreds, or patches. This contingent of 
menstruation is sometimes met with in uterine deviations, catar- 
rhal endometritis and menorrhagia, and is much more easily 
cured. 

Sterility is as common and constant a symptom of membranous 
dymenorrhcea as is the shedding of the membrane itself. And 
there can be no better guarantee of the cure of 
a case of this form of dysmenorrhcea than is fur- 
nished by a fruitful conception and labor at term. The clinical 
history of barrenness often includes the history of old skin affec- 
tions which, in some unaccountable way, have interfered with the 
function of reproduction. The remarkable effects of certain 
mineral waters as a cure for sterility, and for complicated disorders 
of the catamenial function, can best be explained by their value 
in some chronic cutaneous diseases which have first been repelled, 
and then resisted other modes of treatment. 



Sterility as a sequel. 



MEMBRANOUS DYSMENORRHEA. 237 

Anatomically the epithelium is the epidermis of the mucous 

membrane. Clinical experience has long since demonstrated 

the mutual sympathy and morbid relations of these two surfaces. 

The occurrence of a metastasis of disease from 

The skin and the uter- one t ^ Qther j j • remarka- 

me mucous membrane. 

ble. Indeed it is very common, more espe- 
cially in cases of those membranes which, like the lining of the 
nose, of the throat, and of the utero-vaginal tract, arc in direct 
continuity with the external integument. 

The modern classification and description of skin affections is 
quite in accord with the idea that, under certain circumstances, 
almost any of them might be translated to the uterine mucous 
membrane. The moment we define eczema as " a catarrhal 
inflammation of the skin,"* we have declared upon its proneness 
to migrate from the outer to the inner surfaces of the body, and to 
work mischief in them. 

Manifestly, the internal lesion, which is due to this cause, will 

be intractable, if not grave in character, in ratio with the delicacy 

of the function involved. For the monthly 

Practical deductions . . . 

formation, enlargement, separation and repro- 
duction of the uterine mucous membrane, its progressive changes, 
its restrogressive or fatty degeneration, and the escape and cessa- 
tion of the flow are so many physiological steps, that such an 
invasion would almost certainly interrupt or modify. And it 
might very easily change the natural and proper exfoliation of the 
uterine epithelium at the month, into a morbid separation of the 
subjacent mucous layers, and the shedding of a thick and tough 
cast of the uterine cavity. 

That these identical consequences do sometimes follow the 
repercussion of an eruption, I am fully persuaded, not only because 
I have been able to trace the beginning of a membraneous dys- 
menorrhea directly to such an accident, but also because I have 
found it possible to cure this secondary form of the disease through 
a knowledge of this fact, and by using it as a key to the special 
therapeutics of the case. 

Two of my colleagues have recently consulted me concerning 
the best treatment for membranous dysmenorrhea, each of them 
having a case of the kind under his professional care. The above 

*A Handbook on the Theory and Practice of Medicine, by F. T. Robert, M. D., etc., p. 1018. 



238 THE DISEASES OF WOMEN, 



theory of its exceptional origin was explained, and they were 
asked to inquire particularly with reference to 

^ Corroborative expert- ^ ^.^j ^^ Qf ft p^oiM Qr coincident 

skin affection. The following evidence afterwards 
supplied by these gentlemen, has the merit of being fresh without 
having been fabricated expressly to support the theory under con- 
sideration. 

Case. — This case is reported by Prof. Gr. A. Hall, M. D., whose 
notes read as follows: "Mrs. M., aged thirty-five years, resides in 
Chicago. The menses first appeared at thirteen years of age, and 
were natural until her marriage at twenty-two. She has two 
children, the first of which was born ten months after marriage, 
and the other three years later, with one abortion since that time. 

" During her youth and up to the period of her first labor, she 
was troubled with the ' hives," or nettle-rash, but after the birth 
of the child it ceased, and she had nursing sore-mouth for weeks. 
This was followed by a chronic diarrhoea, which lasted for several 
months. The tongue has remained soft, patulous, and spongy, 
and is sometimes slightly ulcerated. 

After the diarrhoea was controlled, a small round spot, as big as 
a half-dollar, appeared on the inside of the left thigh. It came 
first before, and remained during the menstrual flow. It looked 
very red, and was attended with an intolerable itching, but it 
disappeared nearly three years ago, at the time of her miscarriage. 

The latter was not painful, but after a moderate flowing for 
twenty-four hours, the embryo and placenta were thrown off 
intact. Ten days later she had secondary haemorrhage which 
lasted for ten weeks. She was greatly reduced in strength, and 
has never fully recovered her health. 

" Four weeks after the cessation of that flow the menses were 
resumed, and for the first time the membranous shreds and casts, 
of which I send \ou a specimen, appeared. Her appetite became 
morbid, and she craves starch and salt. Since her miscarriage she 
has never had the itching spot on the inside of the thigh, or any- 
where else externally. The catamenia are now attended with 
moderate pain and flowing for three days, when the membrane is 
extruded, after which the pain ceases, and the flow continues for 
three days longer, but moderately." 

Case. — For the details of this case I am indebted to J. E. Mor- 



MEMBRANOUS DYSMENORRHEA. 239 

xison, M. D., formerly of Hyde Park, Illinois. " Miss G.JVL, 
twenty-three years of age, began to menstruate in her twelfth 
.year. From her second year until puberty she had suffered from 
running sores, and occasionally from an eruption like bee-stings, 
with a fine rash over the body, but especially about the waist. 
For the first three years, or until she was fifteen, her skin was 
never healthy, nor was the menstruation either painful or too pro- 
fuse. 

" About this, time, however, the eruption would sometimes 
disappear from the external surface, and this change was always 
observed to increase the monthly pain. For the last four years, 
excepting only at very long intervals and temporarily, no sign of 
the skin affection has shown itself; but the dysmenorrhcea has 
become more and more pronounced. Within that time it has 
assumed the membranous form, and firmly organized shreds are 
thrown off at every return of the ' period.' Her suffering in 
that interval has been very severe, and thus far has resisted all 
medical aid." 

Treatment. — Concerning the curative indications which are 
deducible from this bit of clinical experience, we have to acknow- 
ledge that as yet they are neither very explicit nor complete. To 
have treated only eight cases of this particular kind of membrane- 
ous dysmenorrhoea, and to have been consulted in perhaps a 
dozen others by letter and otherwise, does not warrant us in 
dogmatizing upon its special therapeutics. The temptation to 
speculate upon this subject, however, is very strong, but we for- 
bear. For what a remedy " ought" to do, and what it really will 
do, are not always the same thing. 

Where the precise character of the eruption which has pre- 
ceded the menstrual lesion is unknown, we can not, perhaps, 
do better than to begin the treatment with the use of Sulphur. 
In the case already referred to, where the eruption had not 
been seen for eighteen years, this remedy, in the thirtieth dilu- 
tion, had the desired effect, and produced a marked and lasting 
amelioration of the uterine symptoms. 

But, if the nature of the eruption can be determined, either by 
direct inspection, when it crops out occasionally; through the 
description of an intelligent parent, or patient, who remembers 
just what it was; or, by the ferreting action of sulphur, we shall 



240 THE DISEASES OF WOMEN. 

know better how to proceed. In this case we venture to recommend 
the following practical hints for trial and confirmation, or rejec- 
tion, as they shall prove worthy or otherwise. 

If the eruption is, or has been, like urticaria, give arsenicum 
alb., rhus tox., or urtica urens. 

If what is vulgarly called the " hives," apis mel. (in the third 
decimal trituration), belladonna, chamomilla. 

If it is, or was, herpetic or vesicular, cantharis, rhus tox. 

If squamous, or " scurfy," borax, arsenicum, mix mosch., dul- 
camara, silicea, sepia. 

If scrofulous, and otherwise unclassifiable, sulphur, calc. carb. ,, 
hepar sulph., mercurius. 

If syphilitic, thuja, nitric acid, mercurius iod., kali iod., meze- 
reum. 

If from suppressed rubeola, or if it alternates with ophthalmia, 
Pulsatilla; or, in the former case especially, cuprum acet. 

If it is erysipelatous, belladonna, cantharis, rhus tox., apis 
mel. 

Should further experience verify the importance of knowing 
that repelled eruptions do sometimes cause a membranous dys- 
menorrhoea, this limited and imperfect list of remedies will doubt- 
less be very much changed and enlarged. It is not improbable that 
there are some medicines which, although \,hey are not now sup- 
posed to possess any curative relation to the disease in question, 
may yet prove, through this general indication, to be very useful 
in its treatment. Among these are doubtless bromine, mercurius f 
bryonia, phosphorus, ustilago, and collinsonia canadensis. 

There are undoubtedly good grounds for confidence in the vir- 
tues of calcarea curb, as a remedy in this particular variety of dys- 
menorrhcea. It does not appear to be suited to all cases, and 
certainly does not deserve to be extolled as a specific ; but, when 
it is appropriate, its curative action is quite as marked as it often 
is in too frequent menstruation and in menorrhagia. I have no 
question that, as a uterine polychrest, it is possessed of an inti- 
mate and specific relation to the fatty changes which occur each 
month in the uterine epithelium, the physiological separation of 
which permits and provides for the exit of the menstrual blood 
from the surcharged capillaries. We have a forcible illustration 
of this quality of the calcarea, in its ability to discuss certain 



MEMBRANOUS DYSMENORRHEA. 241 

morbid growths, which it resolves away through a similar meta- 
morphosis; but more crudely, in the power of lime to detach the 
pseudo-membrane in croup and diphtheria. Our Avorkers in the 
materia medica, and in gynaecology, should define this relation , 
and develop this suggestion - . 

The frequent indication for calcarea carb. in scrofulous and 
other skin affections, is suggestive of its value in the membranous 
dysmenorrhea, which is secondary upon these eruptions. With 
the few exceptions in which I have prescribed the sixth or the 
twelfth attenuation, I have always given the third decimal tritu- 
ration in these cases. 

If we find, in a given example, that dysmenorrhcea due to this 
cause is complicated with ovaritis, or rheumatism, the prescription 
may need to be modified. But it should not be forgotten that 
ovaritis itself is as likely to result from certain suppressed erup- 
tions as it is from the sudden metastasis of a gonorrhceal inflam- 
mation. 

In a certain ratio of cases, the best-chosen remedy that is pre- 
scribed on these, or similar indications, will fail to complete the 
cure without manual assistance of some kind. This is more 
especially true of the treatment of membranous dysmenorrhcea 
when it co-exists with retroflexion (not retroversion) of the womb. 
Under these circumstances the reposition of the organ, as a con- 
dition for the prompt and ready exit of the flow, allays and averts 
the tendency to a moulting of its nidal membrane. And the 
effect of this expedient is still more decided if a free dilatation of 
the cervical canal is also secured at the month. 

It is possible that this disease may arise as a sequel to diphtheria, 
when it would require to be treated accordingly. But the off- 
hand method of prescribing for it as though it were alwa}^s and 
strictly a pseudo-membranous affection, is not only unsatisfactory 
in theory, but unsuccessful in practice. 

BORAX IN MEMBRANOUS DYSMENORRHCEA. 

For the notes of the following case I am indebted to Dr. A. P. 
Throop, of New York. You will find it in the Transactions of 
the Homoeopathic Medical Society of the State of New York, vol. 
X, 1872, p. 279 : 

Case. — Mrs. P., aged 21 years, married fifteen months, came to 

16 



242 THE DISEASES OF WOMEN. 

me for treatment September 4, 1871. She had no children and 
had never suffered from miscarriages, but had been complaining for 
about a year of irregularity in menstruation, as follows: The 
menses appeared four or live days too early, and continued four- 
teen ckiys unattended with pain. Eight months since she noticed 
shreds of membrane mixed with the menstrual discharge. There 
wasatthis time no dysmenorrhea, but the period occurred more fre- 
quently, every three weeks, and sometimes lasted for sixteen days. 
This condition continued until the patient applied for relief from 
the severe clysmenorrhoea,with intense uterine tenesmus or k ' bear- 
ing down " pains from which she was suffering. 

Prescribed secale cornutum, pure tincture. The pain was not 
relieved at once, yet it ceased, as did also the discharge, soon after 
the passage of pieces of membrane of the same character, but 
larger than those previously passed. The discharge continued only 
three days after the last shred of membrane was passed. 

The menses again appeared on the 28th of September, with 
severe dysmenorrhcea, lasting seven days, at the expiration of 
which time a much larger, though similar membranous substance 
was passed. The patient, on this occasion, describes the substance 
as being two or three inches in length, and having "a sort of 
three-cornered shape." Previous to this no mention had been 
made of passing these unusual substances, but the history of this 
feature of the case was given in answer to my questions. 

The patient was requested to preserve this last unusual men- 
strual product, and, on examination, it proved to be a perfect 
membranous cast of the cavity of the uterus, triangular in shape, 
with that portion corresponding to the canal of the uterine neck 
a little longer than the angles corresponding with the cornea. It 
was ascertained to be hollow, and its external surface was studded 
with little villous prolongations. 

This membranous product, with the history and symptoms of 
the case, made the diagnosis easy, — membranous dysmenorrhcea. 

Treatment. --As suggested by Prof. Ludlam, of Chicago, pre- 
scribed borax 1, three times a day, till the next period. 

The next period occurred the 25th of October. Dysmenorrhcea 
much less, no cast, only shreds, less in size than for months, and 
the general condition better. 

The last prescription of borax 1, was given November 21st. In 
January, 1872,1 called at the patient's home, being desirous to 
know the sequel of the case, and ascertained that there had been 
no more dysmenorrhcea, as the period had not again appeared, and 
the patient was pregnant. As pregnancy and membranous des- 
quamations from the inner wall of the uterus are not compatible, 
the membranous dysmenorrhcea is supposed to be cured. 

On the 7th of August, 1872, she gave birth to a tine, healthy 



MEMBRANOUS DYSMENORRHEA 243 

female child, and there have been no symptoms since of any uterine 
trouble. 



MEMBRANOUS DYSMENORRHEA FROM EXFOLIATIVE ENDOMETRITIS. 

Case. — Mrs. M., American, ret. 31, and sterile, began to men- 
struate when 18 years of age. Her mother did not menstruate 
until her eighteenth year. The first menstrual flow was very 
painful and profuse. One year elapsed before the second made 
its appearance. During this time the patient bloated frequently, 
and had nose-bleed, but does not remember whether this occurred 
at the month. During' the two following years menstruation re- 
turned four or five times, the periods unvariably coming while the 
patient was under some nervous strain. The flow at this time was 
very painful, but was not, and never has been, accompanied by 
headache. 

From her 18th to her 21st year, — the time of marriage, — ■ 
she taught school, and on her way to and from school was often 
exposed to stormy weather. She remembers that frequently she 
has sat for hours with wet feet. Two weeks after marriage the 
menses again appeared. At their cessation she was seized with 
an acute inflammation of the bladder and kidneys. This lasted 
four or five weeks in an acute form. The paki on voiding urine 
continued for more than a year. Upon recovering from this illness 
a leucorrhceal flow began. 

Up to this time her geueral health had been good, but it now 
began to decline. Two years later, during' a menstrual period, a 
falling of the womb took place. This prolapse is aggravated at 
the menstrual period. Some two years later the patient began 
treatment. A local examination was made and the case called one 
of anteversion. An instrument was introduced into the womb to 
replace the organ. This was repeated four or five times. Fail- 
ing to keep the uterus in place a Macintosh supporter was ad- 
vised. After a four weeks' trial this was abandoned on account 
of the inflammation caused by it. 

As soon as this subsided, the physician began the use of sponge- 
tents. About a half-dozen of these were inserted during a period of six 
months, on each occasion producing more or less inflammation. 
But one flow occurred during this time. This was profuse, and 
with the blood black clots were discharged, pieces of decayed 
flesh, and stringy substances. A diagnosis of membranous clys- 
menorrhoea was then made. 

Xo especial treatment has been taken since,— a period of six 
years. No change has taken place in the character of the flow. 
During the last three years she has had a severe cough accompanied 
by an expectoration of thick mucus. During stormy weather 



244 THE DISEASES OF WOMEN. 

a sharp pain is felt in the apices of the lungs. All these pec- 
toral symptoms are relieved by the now, and do not again occur 
until six weeks or two months after the flow. 

Patient stopped menstruating one week ago ; feels weak ; has 
bearing down pains when erect, with a sensation of smarting in 
the womb, and an irritated feeling in the vagina; some pain on 
urinating; bowels constipated; arid she is troubled with haemor- 
rhoids. 

On physical examination. — The cervix is depressed and points 
toward the hollow of the sacrum, the womb lying transversely 
across the pelvis. The fundus is inclined forward (ante version). 

The internal os is open , the internal surface of the uterus is very 
sensitive, and its depth is three and one-fourth inches. There is 
no especial tenderness of the ovaries. 

In response to inquiries, the patient says rheumatism is not a 
family complaint, and that she has had no eruption on the skin 
since a child, but that there is a tendency toward consumption in 
the family. 

I have cited this case in illustration of a rare form of dysmen- 

orrhoea which is both membranous and inflammatory. The case 

is still further complicated by the uterine de- 
Rarity of such a ease. . , . , . , , . . , , n ... , 

viation, whicn very likely had something to do 
with causing it. For versions of the uterus which occur at or 
about puberty, are almost always the result of flexions ; and it is 

not improbable that this case may have begun 

Version as a factor of . . , , . . , , -. . n . , . . , -, ,. 

with the bending of the uterus upon itself as a 
sequel of her first " period," and that the long interval between it 
and the second, resulted partly, or wholly, from this cause. 

Be that as it may, the attempt to keep the organ in situ by 
means of an infra-uterine stem was the worst thing that could 

possibly have been done, for it almost necessarily 

Mal-treatment by the . , -. ... ,. - ,, ,. . , 

stem-pessary. induced an inflammation of the lining membrane 

of the womb, when that membrane had already 
been congested by the displacement. Under these circumstances 
the careful gynaecologist would no more think 
of leaving" a stem in the cervical canal than he 
would of placing a sponge-tent there while there was any peri- 
uterine inflammation. 

There are two or three reasons why you should be careful to 

differentiate this from the more ordinary forms 

of membranous dysmenorrhcea. In the first 

place the remedies that are suited to exfoliative endometritis are 



OVARIAN MEMBRANOUS DYSMENORRHEA. 245 

not those which are most successfully used in the treatment of the 
common type of deciduous dysmenorrhea. They include the dif- 
ferent preparations of arsenicum and mere urius, the mineral acids, 
and baptisia. 

In the second place, all sorts of local treatment, including the 

use of sponge- tents, the resort to intra-uterine injections, the 

wearing of pessaries, the dilatation of the cervix 

; nfflo e atroa S 10Cal0 ° ntra " b y ^ meailS ' a » d eVe11 the P ; ^g e of t!le 

uterine sound, or the probe, will be mischievous, 
and are contra-indicated in exfoliative endometritis. We may 
permit the use of warm sitz-baths, or hot water vaginal injections, 
and of enemata, to keep the bowels open, without fear of doing 
harm, and with the prospect of good results in some cases. 

This patient has now been five months under treatment. She 
has taken belladonna 3, during the period, and arsenicum jod., 3, 

during the interval. The result has been that 

Result of treatment. .'",„. 

instead ot returning every nine or ten weeks 
only, her periods recur every five or six weeks, and her local suf- 
fering, as well as her general condition, have improved in a coi- 
responding degree. She is very anxious to become a mother, and, 
if she could conceive and carry her offspring to term, it is very 
likely that she would be radically cured. 

OVARIAN MEMBRANOUS DYSMENORRHEA. 

Case. — Mrs. comes from a neiodiborino; State. She is 

twenty-six years of age, and has been married six years. She has 
never had any children, but has had an abortion at the sixth 
week. 

She began to menstruate at thirteen; there followed an interval 
of two months, and then the periods were regular until after her 
marriage, since which time they have varied from three weeks to 
three months. When she goes over two months, there is alwa} 7 s a 
membrane expelled, but at no other time. The periods last four 
and five days, and the longer the interval, the greater the pain and 
suffering, until the membrane is expelled, when the flow con- 
tinues, but without pain. There is constant pain in the left 
ovarian region, and on the outside of the left ankle, but none in 
the limbs. The infra-mammary pain is pronounced, but passes 
away when the flow begins, and does not come at any other time, 
but is greatly increased by any unusual delay in the menses. 

She has no leucorrhoea, no vesical trouble, and no constipation 



246 THE DISEASES OF WOMEN. 

she sleeps best on the affected side, and has an almost constant 
vertex headache. 

On local examination, the womb was found somewhat ante- 
flexed, the canal of the external os was patulous, and the cervix 
was swollen. The introduction of the sound revealed a tortuous 
canal, and the depth of the womb was three and one-half inches. 
There was a slight corporeal cervicitis, and a little haemorrhage 
followed the introduction of the sound. 

In addition to the symptoms just given, there was a slight 
laceration of the cervix, which, although it happened to be of little 

consequence in any other way, disclosed the fact 
utlrL buttou " hole os that she had had an abortion, or rather, that some 

foreign body other than the membranes, must 
have been expelled from the uterine cavity. In fact she did not 
confess to having had an abortion until I told her that such must 
have been the case, when she remembered that she had had such a 
mishap in her early married life. You must keep a sharp look 
out tor this button-hcle os in making your local examinations. 
The theory advanced by Oldham, that ovarian inflammation is 

the prime factor in some cases of membranous 

trat 1 eT mSthe0r " illU3 " d y smeil0lThcea ' is illustrated by this patient's 
history. If we can cure the ovaritis, the men- 
strual difficulty will disappear, and there is no valid reason, at 
least in so far as her own health is concerned, why she may not 
conceive and go to term. 

This woman has been taking gelsemium 3, four times daily with 
excellent effect. All of her symptoms have improved. The 
menses now return every four or five weeks, and 
in the two last periods there has been no exfolia- 
tion of shreds, no labor-like pains, and almost no burning or aching- 
in the ovary. I am bound to tell you, however, that something 
of this result, and perhaps the whole of it may be due to the fact 
that for several months she has been living apart from her hus- 
band. 



LECTUKE XV 



MENORRHAGIA. 



Menorrhagia. Case.— Differential diagnosis in cancer; modes of examination; surgical 
treatment. Case.— Uterine disorders complicated with malarial fever. Case. 



Case. — The first case to which I will direct your attention, this 
morning, is one of menorrhagia. The patient, Mrs. A., is 46 
years of age. Three years ago she had a miscarriage at four 
months, since which time she has never been quite well. 

" Is the flow very profuse, madam?" "O, yes, sir; it is very 
bad when it comes on." "Do you have it all the while, or only 
at particular times? " "Xo, sir; it only comes on when I have 
my monthly sickness." " Will excitement or fatigue produce it at 
any other time?" " Xo, sir." "Do you have any pain?" "Yes, 
sir; I am troubled with awful pressing-down pains in my hips 
and the small of my back." " Have you headache at these times 
also?" " I have a distressing headache so loug as I continue to 
flow." " What is the character of the flow ; is it quite natural? " 
" At the first it is, sir, but afterwards it is like any other bleed- 
ing, bating the dark clots which sometimes come away when I 
have those awful bearing-down pains." "Are your courses regu- 
lar? " " Xo, sir ; they sometimes come on every three weeks, and 
sometimes not so often." 

Menorrhagia signifies a profuse menstruation. It may or may 

not be painful. The flow is excessive, prolonged, hemorrhagic, 

and debilitating. Women who have attained 

Definition of. „ ° . . 

the age ot our patient, in other words, who are 
more than forty years old, but who have not passed the climac- 
teric period, are of all others the most liable to this disorder. 

In them the return of the menstrual period is prone to be 
irregular. Sometimes, as in this case, it is too frequent, the in- 
terval being less than a lunar month. Again, 

Variations in time. . . "r • i t . -,. 

this interval is so prolonged as to occasion dis- 
tressing symptoms, due to the suppression of an accustomed flow, 
or anxiety, lest conception may have interrupted the function 
altogether. 

You will frequently be consulted in similar cases. A very im- 

247 



248 



THE DISEASES OF WOMEN. 



portant point is to make out a proper diagnosis. Heemorrhao-e 
from the uterus may result from polypi, fibroids, 

Differential diagnosis of . .. l j i ■> > 

cancer, abortion, menstrual congestion, chronic 
metritis, or from sub-involution of the uterus, or after delivery at 
full term. Uterine hemorrhage from a polypus, or cancer, may 
occur at any time and without premonition. It is metrorrhagia, 
and has no fixed period of recurrence. Menorrhagia is always 
and evidently connected with the function of menstruation. The 
attack occurs with all the regularity of the menstrual flow. The 
interval is as well defined as in a case of intermittent fever. It 
may he of two, three, or four weeks duration, but the haemorrhage 
is evidently determined by the accession of the catamenia. 

If you explore with the sound and the speculum you can detect 
a polypoid growth, or a cancer, if it exists, but a local examina- 
tion of the uterus in menorrhasfia proper, re- 
Modes of examination, -ni ii 

veals nothing especially abnormal, or pathog- 
nomonic, unless it be an increased depth of the organ. The 
mucous membrane is injected with blood, and more highly vascular 
than in the inter menstrual period, but this is always the case in 
the monthly sickness. The weight of the womb is always in- 
creased by the afflux of blood to it during menstruation. 

Excepting chronic metritis, with uterine sub-involution, the 

lesion that you will most frequently recognize in menorrhagia is 

sub-acute ovaritis. One of the ovaries is tender 

Complicating- lesions of. . ,, , . „, 

to pressure, especially at these times. I he 
patient cannot lie upon the affected side. She complains of lame- 
ness in the corresponding limb. At huch times urination is pain- 
ful. Strangury is a frequent and annoying symptom. The effort 
at stool increases the suffering, The pain extends from one ovary 
across the abdomen, or both ovaries maybe affected from the out- 
set. This pain, which is ordinarily dull and deep-seated, becomes 
acute like that of peritonitis, during the men- 
strual crisis. If you fail to detect any swelling 
through the abdominal parietes, the double touch may disclose a 
tenderness and tumefaction that will readily explain the suffering. 
It often happens that such symptoms date from, a miscarriage. 
This is very likely to occur if the foetus has 

From a miscarriage. . " „ : - 1 . - 

been carried long enough for the placental at- 
tachments to be well-formed. In the case before you an abortion 



MENORRHAGIA. 249 

occurred at the fourth month. Sub-acute ovaritis is a frequent 
cause of abortion. In many cases the affection runs a kind of 
latent course and the physician fails to discover the real lesion. 

This patient complains of pain in the region of the right ovary, 
which is acute at the menstrual period, and dull or sub-acute in 
the interval, worse upon fatigue; of lameness in the right leg 
and inability to lie comfortably upon the affected side. 

I have found, upon making a local examination through the 

vagina and the abdominal parietes, that this ovary is swollen and 

very tender to the touch. With the instructions 

Local examination. , 

that you have already had upon the uterine 
sympathies you are prepared to understand how ovaritis some- 
times causes menorrhagia. 

Treatment. — For practical reasons we divide the treatment of 

menorrhagia into that proper during the continuance of the flow, 

and that appropriate to the interval. To meet the first indication 

very little skill is required. If the flow is passive 

^Remedies during the and pamless? or nearly go? the pat ient of ail 

haemorrhagic diathesis, with hemorrhoids, or 
varicose veins, hamamelis is the appropriate remedy. It will also 
be indicated in case of marked ovarian irritation or inflammation, 
especially if the attack is sudden and its course rapid. It may be 
applied locally over the ovaries and indeed upon the whole abdo- 
men. Given internally in the first or second decimal attenuation, 
the t dose should be repeated at short intervals. If the flow is 
bright red, but passive, and accompanied by gastro-intestinal 
irritation, you may give ipecacuanha. China is called for when 
repeated floodings and leucorrhceal discharges have weakened the 
patient greatly. You may sometimes alternate this remedy with 
ipecac, with the best results. This is an old and favorite prescrip- 
tion. 

Sabina and secale cor. would be appropriate to menorrhagia 
when complicated with dysmenorrhea. The latter is more 

serviceable in post-partum haemorrhage. These 
comp^ a nons°. r PeCUhar remec ^ es are tne more important and reliable in 

examples of the kind, when the design is simply 
to arrest the flow. As auxiliaries, rest in the recumbent posture, 
quiet, the local use of hot water, and cool, acid drinks are neces- 
sary. 



250 THE DISEASES OF WOMEN. 

In the constitutional treatment proper to the interval we should 
take into account the peculiar temperament and dyscrasia of the 
patient, as well as the local lesions and symp- 
intervai men "* toms. If there is sub-acute ovaiitis, the symp- 

toms may require hamamelis, sepia, platina, 
bell., or some similar remedy. When, as in the case before us, the 
menses are too frequent and profuse, and especially if the patient 
is of a strumous habit, with a tendency to pectoral disorder, the 
calcarea carb.,is_par excellence the appropriate remedy. We pre- 
scribe for this patient hamamelis virg., 2d decimal trituration every 
two hours during the flow; and calc. carb. 3d decimal trituration, 
morning and evening, throughout the inter-menstrual period. 

In the Hahnemannian Monthly for December 1870, you will 
find an excellent article by my friend Dr. O. P. Baer on the 
therapeutics of uterine haemorrhage. His remarks are so plain and 
practical that I will cite a few of them. He says : 

"I think belladonna one of our best remedies in haemorrhage 
from the uterus. Its sphere of action is greater than any other 
known remedy. I have watched its actions so constantly, for now 
nearly twenty-five years, have noted the symptoms relieved by it 
so often (many of which have never been recorded), that I have 
no hesitancy in terming it the king of remedies for uterine haem- 
orrhage. Ipecac does well in its limited sphere, of which nausea 
and vomiting are the chief characteristics. And mind you, this 
nausea must proceed from the stomach alone, and the discharge of 
blood be increased with every effort to vomit. This nausea does 
not affect the system particularly, otherwise than by inducing 
increased debility. Belladonna also relieves nausea, and particu- 
larly, when there is a wave-like feeling, or undulating sensation, 
or pulsating tremor all over the whole person, from head to foot; 
and a sick pulsation even in the fingers and toes. This symptom I 
have often met with, particularly in severe haemorrhages of mis- 
carriages, and belladonna m such cases always gives prompt relief. 
Ipecac would fail. I have known it to fail in just such cases. The 
ipecac nausea gives a weight in the stomach and no further, while 
belladonna gives nausea with rumbling in the whole abdomen, 
with great weight from above downward. Gentle pressure upon 
the uterus may cause nausea, and should it do so no other remedy 
is so promptly effectual as belladonna. Where the moving of the 



MENORRHAGIA, 



251 



hands or feet cause the same feeling' of nausea, with wave-like 
swimming (vertigo) of the head, bell, again, is the only reliable 
remedy. *.*-*•**. In the belladonna nausea theje is rarely 
retching, or heaving, while in ipecac there is upward heaving, 
raising the abdomen, bowing the back, and straining tu vomit. 
The action of belladonna is deeper-seated, more quiet, and more 
insidious. Chamomilla nausea in haemorrhage is one accompany- 
ing 1 fainting. A chamomilla nausea is rather lisdit, though always 
attended by a feeling of fainting. Belladonna has a feeling some- 
what similar, such as a sinking feeling, just as if the bed was going 
downward by undulations. Podophyllum resembles belladonna 
in one particular, which is, an all-over sickness, and with the 
general nausea, she feels perfectly indifferent and desires to be let- 
alone. I have seen cases where podophyllum did good work, 
where the patient would say, " Oh, I am so deathly sick !" 
" Where are you sick?" the response would be, " All over." A 
few doses of pod. 30, or 200, would check the whole trouble. 
But belladonna comes in so often as king, that I seldom need to 




Fig. 27. Penrose's Uterine Polypus Forceps. 

resort to other means. Give bell, early, and many of the worst 
symptoms fail to come." 

The surgical treatment of monorrhagia consists in the 




Fig. 28. Hodge's Modification of Aveling-'s Polyptrite. 

removal of the cause, as, for example, in extracting intra- 
uterine polypi and fibroids, and the removal of 
granulations from within the cervix. Excep- 
tionally, where fibroma can not be removed, the 

haemorrhage may be arrested by a free dilatation, or even by an 



The surgical treat 
ment. 



252 THE DISEASES OF WOMEN. 

incision of the neck of the womb; and in the worst cases of inter- 
stitial and of sub-peritoneal fibroids, Battey's operation may be 
expedient merely with a view to the arrest of the haemorrhage. 
These forceps answer very well for twisting off the smaller mucous 
polypi located about and within the os-uteri, and which often 
bleed so copiously. 

NITRIC ACID IN MENORRHAGIA. 

Every practitioner of considerable experience has encountered 
cases of metrorrhagia supervening abortion, or that were incident 
to the climacteric, that have resisted all the 
flb ^o n. rhaRia ^^ ordinary means of arrest. The haemorrhage 
has continued for weeks, perhaps, in a passive 
and irregular manner. As a consequence, the patient has been 
greatly reduced and discouraged. There is a loss of appetite, 
headache, malaise, and a series of symptoms that are chargable 
to the continued drain upon her physical resources. She cannot 
sit upright, or stand erect, but the difficulty is increased. 

These cases are very annoying, perplexing, and tedious, and 

sometimes tax our skill to the utmost. Perhaps the various 

astringents have already been tried, but with- 

r Nitncacidasadernier out &y&{L Q ^ ^ mQre ^^ ^ familiar 

remedies, such as ipecacuanha, china, secale 
cor., sabina, crocus, hamamelis, trillin or the erechthites, may 
have failed in your hands. In such cases, the nitric acid will 
sometimes answer an excellent purpose. My habit is to give it 
in the second or third decimal attenuation, the dose to be repeated 
every one to three or four hours, according to the urgency of the 
symptoms. 

Case. — In consequence of a rough ride in the sleigh, Mrs. , 

aged 28, aborted at the second month. For the first few hours 
she had considerable pain. But the uterine contractions came on 
regularly, and the embryo was soon expelled. Of course, there 
was no well-formed placenta at this early period of pregnancy. 
The post-partum haemorrhage was profuse and long-continued. 
When the pains had ceased, the secale which she had been taking 
failed to have any more influence over the flow. The flow then 
became passive, and the discharge dark-colored and shreddy. 

As the result of keeping her in the horizontal posture, and upon 
an appropriate diet and drinks, she grew better, but soon re- 



MENORRHAGIA. 253 

lapsed again. This was twice repeated. The usual remedies 
would cause the flow to cease for a little, but upon the least 
change of posture, the discharge commenced again. Matters went 
on thus for nearly four weeks, in all of which time she really had 
gained nothing, but lost much in strength, color and spirits. At 
6 p. M. Tuesday of I prescribed nitric acid in the second decimal 
attenuation, twenty drops in half a glass ot water, two teaspoon- 
fuls to be taken each hour. On Wednesday she had had no flow 
since, midnight. The same medicine was directed to be repeated 
once in three hours. On Friday there was no return of the dis- 
charge, and she sat up a little. The remedy was discontinued. 
On bunday she came into the parlor, and afterwards recovered 
rapidly. 

I am aware that there is little in the provings of this remedy 
that is suggestive of its superior efficacy in this variety of haem- 
orrhage; and also that I am not calling vour 

Clinical deductions. ^ . . . ., 

attention to anything especially new or strange. 
In general terms, the nitric acid appears to be indicated in those 
haemorrhages from the mucous surfaces which depend upon the 
destruction and desquamation of their investing epithelium. 
Hence we find it useful in passive haemorrhages from the nose, the 
throat, and the respiratory, alimentary and urinary passages. The 
escape of blood by transudation in consequence of the removal of 
the protecting envelope, would occasion very different symptoms 
from those proper to an active and alarming haemorrhage, while 
in the end the result might be equally serious. 

The opinion that the decidua, or outer envelope of the embryo, 
is formed of the mucous membrane that lined the uterus before 

conception is now very generally received, 
post-menstmai Wh abortion occurs prior to the third month, 

hsemorrhag-e. r ' 

this lining is stripped off, and the cavity of the 
organ is left as destitute of its proper covering as is the spot 
where the placenta was attached, when that structure is cast off 
in labor at full term. If it is not exfoliated entire, the decidua 
may come away in shreds, in which case the attendant haemor- 
rhage persists for a much longer period, and is passive in charac- 
ter. The blood escapes slowly, and is for some 
nitrTclc 1 id indiCati ° nSf0rtime exposed to the action of the air before it 
is expelled from the uterus and vagina. The 
discharges resemble those of melaena. Occasionally they are quite 
profuse. In these symptoms, I apprehend, we have the most 
trustworty and practical indications for this remedy. 



254 THE DISEASES OF WOMEN. 

In the case just cited the other remedies failed to give entire 
relief, because the first stage, and the active symptoms to which 
they were appropriate, had already passed. Then it was that the 
nitric acid could be used with the best results. 

Many cases of dysmenorrhea, more especially of the congestive 

and membranous varieties, merge into menorrhagia. The patient 

suffers extremely in the first stao-e of the men- 

h^morrha?e! nOrrll0eal StTU ^ ^ Vi ° d ' The fl ° W ls B ^ rted wlth g reflt 

difficulty and prolonged suffering, which is 
similar to the first stage of labor. But when the obstacle to its 
egress is overcome, the pain subsides and the discharge is corres- 
spondingly free and copious. The delay and retention of the 
blood in utero, and the violent efforts to force open the internal 
os uteri, have resulted in the partial or complete exfoliation of 
the endometrium, and therefore,' whenever she menstruates, it is 
as if the woman had had a veritable abortion. In one sense the 
haemorrhage is post-partum. In all important pathological re- 
spects, it is identical with that which supervenes upon a miscar- 
riage in the early months of • gestation. The detachment and 
disorganization of the uterine mucous membrane develops the case 
into one of passive haemorrhage, to the relief of which the nitric 
acid is frequently, but not invariably, adapted. 

You are already aware that, at the climacteric, many women 
are liable to protracted haemorrhage, which is apt to be of a pas- 
sive kind, not profuse, but lingering, exhaustive 

Hemorrhage at the nd debilitatin „ This fl 0W is Sometimes ill- 

climacteric. & 

tractable. It may or may not contain strips or 
shreds of what are falsely called "pseudo-membranes," but its 
existence often depends upon the morbid condition of the uterine 
mucous membrane of which I have spoken. In some of these 
cases the nitric acid is invaluable. 

Case. — Mrs. , aged 46, had been ill for five weeks with a 

passive haemorrhage, which dated from her last menstrual period. 
She was much reduced in strength, the pulse was weak and irri- 
table, the lips, tongue and alae nasi were very pale. She com- 
plained of occasional faintness, and disgust of food and drinks. 
The feet were cold, and she had almost complete insomnia. Her 
friends thought her going into a rapid decline. Motion aggra- 
vated the flow. Prior to the last period she had a similar attack, 
which continued about four weeks before the flow was arrested. 



MENORRHAGIA. 255 

I prescribed nitric acid in the second decimal attenuation, to be 
taken as directed in the former case. In two hours the haemor- 
rage ceased. She made a rapid and complete recovery without 
taking any other remedy. 

In these cases the state of the uterine mucous membrane is 

very analagous to that which we meet with in apthous conditions 

and incipient ulcerations of the alimentary 

Practical conclusions. .. . . . , . , ,. 

mucous surfaces, as m stomatitis, typhoid lever, 
and in some forms of diarrhoea and dysentery. Here we have a 
similarity of texture, and there can be little doubt that these 
membranes are susceptible to disease-producing and disease-curing 
agents of a similar character. Possibly the sulphuric, phosphoric 
and muriatic acids might also be useful in some cases of uterine 
haemorrhage. The great benefit derived, in the treatment ot 
haemorrhages, from citric acid in the form of lemonade and oranges, 
and of tartaric acid in grapes, may not be attributable alone to 
their being grateful to the taste. It is not improbable that they 
are of service in a medicinal as well as in a dietetic way. 

MEXORRHCEA CERVICAL EPISTAXIS. 

Case. — Miss M , 19 years of age, has been an invalid for 

four years past. She is not confined to her room except at irreg- 
ular intervals, but is active and able to ride or walk, and to some 
extent to enjoy the society of her friends. She began to menstruate 
at fifteen. The first period came on with a great deal of pain and 
difficulty, but when the flow was finally established it continued 
for three weeks without cessation. After five days' intermission 
it commenced again, but without any considerable suffering. 
Again it continued until almost the end of the month, and again 
it returned with the regularity of the normal monthly discharge. 
In this manner, for four years, the flow has been almost constant. 
The longest interval in which she has ever been free from it, in 
all that time, is seven days. There is no dysmenorrhcea, the loss 
of blood is not excessive, but the flow is passive and painless, and 
continues when she is sleeping as well as during her waking 
hours. Sometimes under strong mental excitement, as when she 
is at a concert or in company, and her mind is diverted, it ceases 
temporarily, and afterwards returns as before. The same effect 
has been observed in consequence of a carriage ride and of a jour- 
ney by rail ; but it is of a very short duration. 

If the flow is arrested, she suffers no inconvenience excepting 
a "rush ot blood to the head," accompanied by more or less ver- 
tigo, headache, flushed fac% dimness of vision, and a heavy, dull 
feeling, with disposition to sleep. At other times her mind is clear 



256 THE DISEASES OF WOMEN. 

and her spirits are good. And yet she feels somewhat weakened 
and enervated by the constant loss of blood. Her appetite is 
good. There is no intra-pelvic pain or distress, no haemorrhoids,, 
no constipation, and no urinary derangement. The only suffering 
noted is a feeling of aching and weariness in the region of the 
ovaries, more especially of the left one, at the month and after 
unusual exercise. During her whole menstrual life her mother 
was subject to a similar haemorrhage. 

This patient's general appearance does not indicate that she is 
ill. She has walked several squares to the Dispensary this morn- 
ing, with less fatigue than you would have supposed possible. 
Her color is somewhat heightened by the exercise in the open air, 
for her sister says that she is usually more pale than now, except- 
ing only when her haemorrhage has ceased and the blood rushes 
to her head. 

It is sometimes very important, in cases of this kind, to discover 

the relation which a passive uterine haemorrhage bears to the cata- 

menial function. If the flow dates from the 

Relation to menstruation. ■ . 

first establishment 01 this inaction at puberty, 
as in this instance, or if it habitually ceases a short time before 
the "period," and then recurs regularly, you may conclude that 

it is essentially a menstrual disorder. There 

A diagnostic rule. . 1 . . _ 

are some exceptions to this rule, as m case ol 
medullary carcinoma, and sub-mucous polypi, and perhaps in 
syphilitic endometritis also ; but, in most instances, the manner 
and time of its advent, and its regular periodicity afterwards 
(even although the period may be longer or shorter than natural), 
are to be taken as evidence of its connection with the process of 
ovulation. 

Nor is it difficult to explain this result. The physiological in- 
jection of the endometrium, which is a condition of the menstrual 
secretion, is relieved and removed when the 
healthy woman has menstruated. But, if she 
is not well, that extraordinary fullness of its vessels may continue, 
even although the menstrual flow has been discharged ; and there 
will remain a passive congestion of some portion of the uterine 
mucous membrane. This engorgement may relieve itself by a 
profuse and copious haemorrhage, as in menorrhagia, or even m 
metrorrhagia ; or it may pass away by a sort of cervical epistaxis. 



MENORRHAGIA. 257 

01 passive flow, In which the local excess of blood oozes out and 
escapes more leisurely. In the former caso the critical and alarm- 
ing haemorrhage is sudden, and of short &i ration ; in the latter it 
is a mere prolongation or continuation of t le menses, without any 
very serious symptoms, until the month is 1 aearly or quite spent, 
and it is time that they should return aga u. One is acute, active, 
and irregular in its recurrence ; the other chronic, passive, and 
distinctly periodical. 

There is another reason why this woman's haemorrhage, although 
go long continued, must be classed as menstrual — a real case of 
menorrhoea. It is that the amount of the flow is 
not influenced by the exercise which she takes, 
or by other circumstances, more decidedly than it is in ordinary 
menstruation. If that haemorrhage depended upon the presence 
of a sub-mucous or interstitial fibroid, a polypus, ulceration, can- 
cerous degeneration, or venous engorgement, the quantity of blood 
lost would vary with her habits. Above all things, it would not 
be lessened by riding and active exercise. 

Viewing this species of haemorrhage as in a sense critical, and 
remembering the " habit " which has grown out of its continu- 
ance, with brief intervals only, for years, we 

Its critical nature. pi 

should naturally expect that the arrest of the 
flow would occasion more or less of suffering and disorder else- 
where. Hence the "rush of blood to the head," of which this 
woman complains whenever the flow has ceased, and which sub- 
sides as soon as that flow is restored. The same cause will some- 
times induce a violent attack of facial neuralgia, or sick headache, 
vomiting, delirium, hysteria, spasms, coma, or even convulsions. 

To show that this disease is not infrequent, and that the case 
before you is a typical one, I will read you some extracts from a 
letter received a few days ago from Dr. R. C. Sabin, of Wiscon- 
sin, a member of the class for 1871-72 : 

Case. — " My patient is now eighteen years of age. She com- 
menced menstruation at fifteen, and the flow has been almost con- 
stant ever since. The longest time in which she has been free 
from it is two weeks, when the interruption was caused by a jour- 
ney by rail. The discharge is of a bright red color, thin and 
watery, and has no odor. After continuing for a month or six 
weeks, the flow becomes stringy and thick, and then ceases for 

17 



258 THE DISEASES OF WOMEN. 

two or three days. Her health is always impaired at the time the 
flow stops, and there is giddiness, sudden flushes of the face, 
blindness, etc. These symptoms pass off as the flow returns. 
The urine is high-colored, and of a strong nauseous odor. 

" She is of scrofulous habit, short and fleshy, and. is troubled 
with frequent moist eruptions. The constant drain does not seem 
to have the least effect in reducing her weight. She was ex- 
tremely fleshy as a child. Her general health seems good, she 
goes to school, and has a gooda appetite 

" She has taken, at different times, sepia, pulsatilla, calcarea 
carb., china, hamamelis and ferrum. The latter benefits her gen- 
eral condition, and, temporarily, lessens the amount of the flow. 
Hamamelis will also check it in a few days, but then she feels 
wretched until the discharge comes on again." 

In these cases you should not fail to make a careful vaginal ex- 
amination before you venture an opinion concerning the nature 
of the disease, or the proper course of treatment 
Necessity of physical to i^ pursued. You may find the cervix uteri 

examination. i- ^ 

tender, swollen, congested, or in a state of are- 
olar hyperplasia ; or a small mucous polyp may have sufficed to 
perpetuate the mischief. Bi-manual examination, and the double 
touch, may discover such a state of ovarian irritation and inflam- 
mation as will account for the symptoms and give you a hint 
toward their relief. 

It is sometimes important to know whether this or other men- 
strual disorders have been hereditary in the patient's family. 
Especial inquiries should be made concerning 
' the hemorrhagic diathesis, or if the patient has 
ever had chlorosis or ansemia. The clinical history of the case 
might also be modified if the woman had ever borne children, or 
been pregnant and suffered an abortion, and in some cases by her 
having nursed an infant. And so also by marriage, intemperate 
coitus, residence in a mountainous, a marshy, or an aguish district, 
by high living, and the free use of alcoholic drinks. For all these 
are so many avoidable causes of the disease under consideration. 
The fact that in this woman's history, as well as in Dr. Sabin's 
case, the haemorrhage has persisted for several 

The haemorrhage may per- years } g pr00 f that it UiaV Continue indefi- 

sist without manliest injury. J i- <J 

nitely, and without any very serious impairment 
of the general health. Its duration may even extend from 



MENORRHAGIA. 259 

puberty to the climacteric, and then expire by limitation. Usu- 
ally, however, such persons survive the change of life with diffi- 
culty, for the arrest of the accustomed discharge is apt to induce 
disease of a more serious character elsewhere. 

One of the most troublesome consequences of this form of uter- 
ine hsemorrhage is sterility. Whatever the state of their general 
health, in women whose pelvic circulation is 

Sterility from. . -i-i--it • 

being thus constantly drained, the vitality of 
the internal generative organs is low. And even if ovulation is 
properly performed, the lining membrane of the generative intes- 
tine is not in a condition to favor conception. Moreover the san- 
guineous flow itself would be very likely, to interfere with a 
fruitful intercourse. Hence you will be consulted for the cure of 
barrenness which, directly or indirectly, is due to such a haemor- 
rhage as this woman has had for the past four years. 

Treatment. — In the whole range of medical practice, I scarcely 
know of a class of cases which is better suited to illustrate the 

efficacy of properly chosen internal remedies, 

Medicine versus Surgery. ..,., • i -i l •• -i • 

conjoined with suitable hygienic regulations, 
than this. Here is a case of haemorrhage which depends upon a 
pathological disorder of one of the most prominent of all the 
bodily functions. It has a definite clinical history. Its symp- 
toms are significant. Its causes are obvious and avoidable. Its 
diagnosis and prognosis are not difficult. Its treatment is similar 
to that of other diseased conditions. And it can be cured by 
therapeutic means exclusively. 

In all these respects such a case as the one before you differs 
from uterine haemorrhage accompanying or following labor or 

abortion, or from habitual and excessive losses 
^v^A^mttt^y ^ blood in consequence of intra-uterine 

growths. In them the haemorrhage is acci- 
dental and more or less dangerous. It is a mere contingency, 
and must be relieved at once, or the patient's life may be sacri- 
ficed. The simple expedient of emptying the womb and securing 
its contraction may be sufficient. But in the passive form of uter- 
ine haemorrhage, connected with menstruation, surgical appliances 
are either powerless or harmful, and no such very general indica- 
tion is presented. We are forced to depend upon uterine thera- 
peutics. 



2(30 THE DISEASES OF WOMEN. 

In the selection of a remedy, or remedies, we should not over- 
look the significance of certain incidental states or conditions, for 
example, the different dyscrasiae, each of which 

General therapeutics. . . . . 

is possessed 01 its own clinical bearing, lhus : 

If the patient is predisposed to haemorrhage, such remedies as 

china, ipecacuanha, sabina, platina, secale cornutum, ferrum, nux 

vomica, natrum mur., hamamelis, trillium, 

For the haemorrhagic r } lus ^ox., calcarea carb., belladonna, crocus, 

diathesis. *' 7 7 ' 

carbo veg., phosphorus, arsenicum alb., and 
sulphuric or nitric acid may be indicated. She should be put 
upon cool acidulated drinks, and enjoined to keep as quiet as pos- 
sible during the first week or ten days of the period especially. 

If she is in a state of chloro-anaemia, the remedy must cover the 
symptoms which are most prominent. Among them you will ob- 
serve such as signify a profound impression of 

For the chloro-anaemia. ' ■*• 

the nervous and circulatory, as well as of the 
digestive and menstrual functions. And, whether the haemor- 
rhage is the cause or the consequence of the impaired quality of 
the blood, the case will have to be treated as one of chlorosis with 
serious complications. 

In case of confirmed scrofulosis with menorrhcea, I apprehend 
it to be of the utmost importance to attend to the physiological 

needs of the organism in advance of medication, 
cachexk? scrofulous First, select a suitable diet, one that can and 

will be assimilated. It should consist of a 
proper and available proportion of the oleo-albuminous elements. 
These should be cooked and presented in a pleasant and palatable 
form, and at a suitable time of the day. The appetite should be 
encouraged by mental diversion and suitable exercise in the open 
air. For the function of haematogenesis, or blood-making, to 
which the lymphatic glandular apparatus is especially devoted, 
must proceed properly, else the quality of the blood will become 
so seriously impaired that haemorrhage will almost certainly 
follow. 

The most prominent remedies suited to this cachexia, and the 
symptoms that are likely to spring from it in this form of cervical 
epistaxis, are calcarea carb., calcarea phos., hepar sulphuris, sili- 
cea, baryta carb., jodium, phytolacca, carbo veg., mezereum, mere. 



MENORRHAGIA. 261 

sol., mere, jod., sulphur, and the nitric, muriatic or sulphuric 
acids. 

In some obstinate examples of this form of passive uterine 
haemorrhage (if your experience accords with mine), you will find 
that when the most carefully selected remedies 
cachexk 6 syphilItIc have failed, as they sometimes do, you will suc- 

ceed in curing it by giving medicines which are 
anti-syphilitic in their character. In this way the kali jodatum, 
kali hyd., thuja, mere, praecip. ruber, and nitric acid, in such po- 
tencies as you shall select, may help you out of the difficulty. Of 
course, if you succeed by giving them upon the theory that there 
was a slight taint of syphilis in the lesion, it will not be either 
prudent or necessary to tell the patient or her friends why this 
particular class of remedies was chosen. 

Ovarian disease is so frequently at the bottom of these haemor- 

rhagic complaints that you should be very careful not to overlook 

it. For, as a rule, the ovaritis precedes the 

For ovarian complications. . i i r> • i 

haemorrhage, and is the cause both ol its long 
continuance and of its periodical return. This is especially true 
if the chronic and unnatural flow dates from puberty. The reme- 
dies which are best adapted to the cure of this complication are 
belladonna, colocynth, hamamelis, lilium tig., lachesis, carbo veg., 
conium, veratrum vir., platina, mercurius corr., and pulsatilla. In 
a word, the cardinal symptoms that properly belong to the lesion 
of the ovaries, when the ovaritis and the haemorrhage co-exist, 
are a more trustworthy guide in the selection of the remedy than 
the quantity, or even the quality, of the sanguineous flow itself. 

Since it is possible that a change of climate may aid in the re- 
covery, one who has lived in a mountainous region may be sent 

to a different section ; or one who has resided 

Change of climate. 

in a low, marshy district, may be transferred to 
the mountains. Sometimes a cure will follow a change from 
the prairies to the sea-side, or vice versa, the object being to bring 
about an entire renovation by a change of external conditions. 
Or a sea-voyage, or salt-water baths, may prove very beneficial. 

While it is requisite that such patients as Miss should take 

_ . ,, . sufficient exercise, it is equally important that 

buitable exercise. x J x 

they should not overdo. Horseback riding, or 
running the sewing machine, skating, or dancing, for example, 



262 THE DISEASES OF WOMEN. 

would aggravate or increase her disorder. The exercise should be 
more gentle and passive. 

I have more confidence in nitric acid, in the second decimal dilu- 
tion, than in any other single remedy in these 

Nitric acid. . J n _ J ^ 

cases, it is not, however, specific. She will 
take it four times daily, and report the result. 

MENORRHAGIA WITH REMITTENT FEVER. 

Case. — Mrs. , aged 30, has been subject to menorrhagia for 

three years past, for the relief of which she has had treatment by 
two celebrated gynaecologists, but without avail. She has taken 
the most powerful drugs, and been subjected to local treatment, 
which consisted in the topical use of astringents, such as the 
tincture of the chloride of iron, tannic acid, a mixture of alum 
and carbolic acid, and the persistent use of the tampon. She is 
confident that these applications have frequently been made within 
the uterine cavity, for her physicians have told her very plainly 
that such was the case. Her loss of blood at the month have 
been terrible, and it has often seemed as if she must die from 
them. 

She came under my care as 'a private patient six months ago. 
The menses had been in the habit of returning every three weeks, 
and continuing, with brief intervals, for from ten to fifteen 
days. The flow at times was copious and drenching, and she had 
frequent spells of fainting and exhaustion. She was pale and 
anaemic, cachectic and bed-ridden. I saw her first at the close of 
the period, and prescribed calcarea carbonica 3, a dose to be 
taken four times daily, and gave her no local treatment whatever. 
She improved from the start to such a degree, that I resolved to 
let well enough alone, and gave her no other remedy. 

When the next period arrived, which was a little later than 
usual, she was doing so well that the calcarea was continued. The 
flow lusted but six days, was much less copious and more natural 
in every way than it had been for years. 

The same remedy and the same experience was continued and 
repeated for four months with the effect to lengthen the interval 
between the periods to four weeks, and to lessen the discharge to 
about the normal quantity. But at the end of this time she ob- 
served that each period was accompanied by febrile symptoms of a 
more decided character than she had ever noticed before, although 
she was persuaded that something of this kind had often been pre- 
sent during the monthly molimen. 

h\ order to be certain of her condition during the monthly 
period, I instructed her to go to bed and to stay there until th's 
flow had ceased. Meanwhile,! visited her every day and discovered 



MENORRHAGIA. 263 

that she was suffering from a pronounced fever of a remittent type, 
for which nitric acid 3, proved to be the remedy. 

It is not an uncommon occurrence for uterine, as well as other 

lesions of function and structure, to be complicated with one of the 

types of malarial fever. Sometimes this lesion 

Complicated with ma- the cause? an J ao; . lin ft fc the consequence of 

larial fever. ' & * 

the fever. In the case under review, when the 
calcarea had done its work, there yet remained a source of 
mischief which it could not counteract or remove. If the type 
of the menorrhagic fever is intermittent, tarantula is the remedy.* 
In this connection, I cannot forbear to remind you, that most 
uterine disorders are not so single and simple as you may have 

supposed, and that, consequently it is very sel- 

Uterine disorders not . . 

always easy of cure. dom that we can succeed in curing them radi- 
cally and entirely with one remedy, no matter 
how carefully it is chosen, how appropriate it may be to the more 
urgent symptoms of the case, nor how persistently it may be 
given. If there is any class of diseases in the treatment of which, 
the superior efficacy of our remedies can be demonstrated, it is in 
the different forms of uterine haemorrhage, when that haemorrhage 
is non-puerperal. It is sometimes astounding to see how our 
attenuations take hold even in the most unpromising cases. But 
the fact remains, that only a very few of them can be entirely 
cured by a single remedy. 

Here is another case which illustrates the tendency of men- 
strual hae morrhages to be complicated with the most varied and 
intractable disorders: 

MENORRHAGIA WITH RHEUMATISM. 

Case. — Mrs. , thirty-six years of age, dates her illness to 

three years ago in the old country, and attributes it to hard work. 
Her menstrual flow returns every three weeks, lasts for from 
eight to twelve days, and is very copious. She has a great deal of 
pain in her back, with sharp catching pains, which begin in the 
left, but have extended to the right side. She must lie either 
upon the back or upon the affected side. She has severe head- 
ache which is aggravated at the month. In advance of the flow 
all of her sufferings, including a nasty taste in the mouth, nausea 
and constipation, are increased to an almost unbearable extent; 
but as soon as the discharge begins, these symptoms are measur- 
ably relieved. She inherits a tendency to rheumatism. 

*Lectures on Clinica] Medicine by Dr. Jousset; translated by Ludlam, p. 46. 



264 THE DISEASES OF WOMEN. 

Under the use of nux vomica 3, spigelia 3, and afterwards of 
colocynth, 3, the menorrhagia disappeared, and the monthly func- 
tion became normal ; but the rheumatism continues, and thus far 
has defied our treatment. 

[At his clinic on Nov. 3, 1880, Prof. Ludlam called attention 
to the fact that this patient had subsequently been very much 
benefited, if not almost entirely cured of the rheumatism by the 
persistent use of macro tin 3. He also took occasion to say that, 
in the case of rheumatism, or almost any other disease which is 
complicated with uterine affections, and more especially with 
menstrual disorders, the rule that we should Avithhold our remedies 
as soon as they have done any good, is unsatisfactory and fallacious. 
The reason lor this fact, for it is a fact, is that in this class of cases, 
especially at or about the menopause, the uterine irritation is a 
more or less constantly acting cause which renews the attack of 
rheumatism, or what not, as soon as the first effect of the remedy 
has passed off. Ignorance of this clinical fact, has caused many of 
our physicians to question the efficacy of our remedies in the 
treatment of chronic diseases when they are complicated with 
uterine affections.] 



LECTURE XVJ 



MENORRHAGIA — CONTINUED. 



Menorrhagia with hemiplegia; do. with Uterine Fibroid ; do. with Convulsions; suppres- 
sion of do. by Astringents; Vicarious Menstruation. 

MENORRHAGIA WITH HEMIPLEGIA. 

Case. — Mrs. , forty-seven years of age has been out of health 

for five years. She has had eleven children. During her last 
pregnancy, when she was about three months along, she was sud- 
denly taken with paralysis of the left half of her body (hemi- 
plegia). After the child was born, however, she recovered from 
it, a result which she attributes to an ex ;essive flooding. She 
now menstruates profusely every three weeks. At times she has 
numbness in the left hand and foot. She took hamamelis 3, three 
times a day. 

Five weeks later her general symptoms were very much im- 
proved. There was still some numbness in the left side, but she has 
not menstruated for six weeks. The same remedy was continued. 

The menstrual haemorrhage was effectually disposed of by this 
remedy, but she afterwards took belladonna with the best result, 
on account of the hemiplegia. 

In this case it is very probable that the approach of the climac- 
teric period, had as much to do with the hemiplegia, as the condi- 
tion of pregnancy. And the menorrhagia was 
tio^° mP ° UndindiCa ~ certainly contingent upon it. The proper 
therapeutics of the case, therefore, complicated 
as it was, turned upon a recognition of these facts and of these 
factors, and hence necessitated the use of belladonna after the 
hamamelis had done its work. 

MENORRHAGIA FROM A UTERINE FIBROID. 

Case. — Mrs. N., aged thirty-three, has had menorrhagia for 
eight years. She has never been pregnant. She first discovered 
the tumor about eight years ago, after having lifted and cared for 
a very sick sister. This tumor is sensibly increased in size with 
every return of the menses. The only pain that she has is with 
the flow, which is very copious, but of a brief duration. At one 
time, however, the menses were suppressed for nearly a year. 

[The class examined this tumor very thoroughly. Its outline 

#>5 



266 THE DISEASES OF WOMEN. 

and texture could be distinctly recognized through the abdominal 
parietes. Prof. L. passed the sound into the uterus, and then 
moved the tumor with the hand upon the abdomen, so as to illus- 
trate the intimate connection between the two. He also said, 
that in this case, the menstruation had become regular and almost 
normal. The growth of the tumor had been arrested, and the 
patient's general health had greatly improved, under the use of 
the Trillin in the 3d decimal trituration. ] 

MENORRHAGIA WITH CONVULSIONS. 

I have had frequent occasion to extol the virtues of Nitric- 
Acid in a certain form of menorrhagia. Here are the notes of a 
case for which I am indebted to Dr. W. H. Parsons, of the Class 
of 1870-71 : 

Case. — Miss , twenty years of age, of nervo-bilious tem- 
perament, with dark hair and complexion, black eyes, and small 
in stature, had been ill for nearly four years. For the first eight 
years of her life she was puny and small, and, though never very 
ill, the skin was always of a yellowish hue, and the flesh very 
soft and flabby. At the eighth year she began to grow in height 
and breadth, and finally became very fat. She continued so until 
her fifteenth year, when her menses appeared. At the second 
month she began to have a peculiar discoloration of the skin in 
various parts of the body. There were dark circles about the 
eyes, with languor, a morbid appetite and a general chlorotic 
condition, and the catamenia did not return. 

The doctor under whose care she was placed succeeded in bring- 
ing on the menses, but the flow did not cease at the proper time. 
The discharge was muco-sanguinolent, dark and offensive, and 
lasted at first about a fortnight. After this it became continu- 
ous, and she lost the record of the month. This state of things 
was unchanged for several months more when the mother 
besought the doctor to stop the flow. Some unknown medicine 
was given which had the desired effect, but she went into convul- 
sions, and the doctor, having decided it as hopeless, relinquished 
the case. As soon as the effect of the drug passed off, the flow 
returned and the convulsions ceased. 

This was followed, however, by twitching of the voluntary 
muscles. For about six months these symptoms continued and 
increased in severity, and her parents abandoned all hope of her 
recovery. Another physician was called, who diagnosticated the 
case as one of menorrhagia. He proceeded to suppress the dis- 



MENORRHAGIA — CONTINUED. 267 

charge and re-produced the convulsions. He then declared them 
epileptic, and treated her for epilepsy. But the girl grew weaker 
and more nervous, and finally he also abandoned the case, saying 
that " she would either outgrow it, or would ultimately die of 
it." 

At the beginning of the third year Dr. was called. He 

declared it to be a passive menorrhagia, and prescribed hamamelis, 
creasote, secale cor., pulsatilla, etc. With these remedies the 
flow was arrested without bringing on the convulsions, and for a 
time the patient seemed to improve. After this she had amenor- 
rhcea (suppressio mensium), for several weeks, and then for six 
months more alternations of suppression and continuous flow. 
She was finally reduced to a mere shadow, passed sleepless nights, 
her right side was constantly in motion, and she was anxious to 
die for the sake of relief. 

Another physician was called, the patient improved, under 
senecin, gelseminum, and secale cor., and the parents soon thought 
they could " get her along" without the doctor. So far as the 
discharge was concerned, she was in a somewhat improved con- 
dition. But generally she Avas no better. In a few months the 
old difficulty returned with renewed violence. 

I found the patient in the following condition. She is very 
much emaciated, and hardly able to walk ; flesh flabby, skin soft, 
discolored in spots, very sallow and dirty looking, hectic flush, 
sensitive, alternate chilliness and flushes of heat, eyes brilliant, with 
dark circles about them, and constantly moving from one object to 
another. Sometimes she sits and stares like an idiot, and acts in 
a very silly manner. She also complains of pains in the top and 
back part of her head. The pulse is quick, small and irregular ; 
respiration hurried ; her body is in almost constant motion, her 
right foot and hand are very restless, particularly at night ; starts 
in her sleep as from fright. She rises at six A.M., but soon returns 
to bed, and almost immediately falls into a deep sleep which lasts 
about two hours, after which she feels weary and languid. She 
dislikes society, is fond of seclusion, and is very despondent. 
Complains of pain in the dorsal region of the spine. The stomach 
is very irritable, with a constant feeling of " goneness," eats little, 
food irritates and causes pain in the stomach. Craves acids, can 
not eat either pastry or hearty food. Tongue is coated and of a 
bluish white color. The bowels are bound, the urine high 
colored. No pain in the uterine region. 

The vaginal discharge is of a muco-sanguineous nature, very 
dark and foetid, darker than the proper flow, with occasional 
clots. 

I stipulated that she should eat what I directed, and nothing 
else, that her room should be changed from a dark and curtained 



2Q8 THE DISEASES OF WOMEN. 

dungeon to an any, pleasant one, exposed to the sunlight, and 
that she should continue under treatment until I pronounced her 
cured, whether it took a month or a year. She was to take all 
the apples and oranges that she could eat, to exercise lightly in 
the open air, and to forego her exhausting sleep in the morning. 
The remedy prescribed was nitric acid 3 (centesimal), four pellets 
three times each day. 

April 17, two days later, no change excepting that her stomach 
is less irritable, and bears food a little better. Continue the 
medicine. 

April 19, improved ; thinks the flow less ; appetite better ; but 
is very nervous and wakeful. Coffea 6 one dose at bed-time, and 
nitric acid as before. 

April 23. Continues to improve ; rested much better ; the 
discharge is very much lessened ; appetite improved ; pulse less 
frequent and more regular. Continue. 

April 26. Improving. Repeat the acid only twice per day. 

April 29. Flow completely stopped. Is very restless, can not 
lie or sit still ; starts at the least noise, seems afraid of every one, 
must get out of bed, looks wildly about, can not sleep. Hyos- 
cyamus 6 two doses at night. Nitric acid discontinued. 

April 30. Slept well, feels refreshed ; had the best night's 
rest that she has had for months. Hyoscyamus as before. 

May 3. Better, sleeps well, is more inclined to talk, and less 
nervous ; eyes less brilliant, appetite better, very little pain in the 
head. A slight discharge from the vagina. Nitric acid again, two 
doses to be taken each week. 

May 15. Found my patient much improved. She has passed 
through her menstrual period, which lasted four days and ceased 
spontaneously two days ago. She feels like a new creature, 
sleeps like a child, appetite good, stomach bears food well, no 
head symptoms, is cheerful and hopeful, glad to see her family 
and friends, her skin is almost natural, and, in brief, she appears 
well. 

Three months later (Aug. 10th), I called upon my patient and 
learned that she had quite recovered, and was in every respect the 
opposite of what she had been. The nervous symptoms^ had 
vanished, the menstrual irregularity had disappeared, and her 
health was entirely restored. 

This case illustrates the ill effects of " forcing the flow" at 
puberty. Here is a young lady of fifteen years. Nature is mak- 
ing an effort to establish the menstrual function. 

Emmenagogues at puberty. . 

bhe is passing through the preliminary stage or 
the crisis, has been sick once, and in due time all will be well. 



MENORRHAGIA — CONTINUED. 26^ 

But her incidental ill-health alarms the parents. A doctor is 
called, and he decides that the " change" is not progressing as it 
should, and that all her difficulties are due to the delay in men- 
struation. Thus far his opinion is well enough. But, forgetting, 
if he ever knew, how delicate the function of ovulation neces- 
sarily is, with what contingencies it is beset, and how easily its 
proper performance may be deranged, he prescribes something that 
is designed, not to prompt, but to compel the flow. 

The consequence is that a train of ills, which might have been 
avoided, is fastened upon her. The flow appears, but it is not 
physiological and healthy. Instead of being 
followed by a spontaneous return in four 
weeks, it does not come at all. A little more medicine, and more 
of tinkering with the most marvelous of all the wonderful pro- 
cesses of the living animal body, and, as if to revenge itself, the 
discharge commences and continues indefinitely, or until it is 
checked again by powerful astringents. 

Now, gentlemen, you know the mischief of the artificial induc- 
tion of abortion. I have shown you how ruinous it is to the 
health of a woman to forcibly interrupt the 

Remote consequences. 

attachments and growth of the germ. In this 
clinic your attention has been called to some of the sequelse of 
this abominable practice. But, let me tell you that, leaving the 
foeticide out of the question, the consequences to the woman are 
no more serious and lasting than those which frequently follow 
the taking of emmenagogues by young girls who are but just be- 
ginning to menstruate. 

The fact that with this patient the menses had already appeared 
should have been a sufficient guaranty that, if she were well in 
other respects, the flow would be regularly 
comm n on' ual intermissi ° ns established. And besides, as every experi- 
enced practitioner will attest, nothing is more 
common than for the " periods," after having come once or twice 
at puberty, to be irregular. Sometimes they skip one month, 01 
two or three, or perhaps even a year, before they return again. 
And this without any material damage to the general health. 
By and by, unless the doctor or the nurse is 

Let them alone. ... . 

impertinent, ignorant or mischievous, they are 
resumed with very little risk, and afterwards become quite regu» 



270 THE DISEASES OF WOMEN. 

lar. But, if you will observe carefully, I think you will find that 
in a very large proportion of cases of intermittent and irregular 
menstruation, amenorrhoea and menorrhagia, the difficulty is 
traceable to mal-treatment of this kind, at or about the period of 
puberty. In this manner it is quite possible for a single doctor, 
who has a passion for what he calls " demonstrative treatment," 
to sow the seeds of evils that fifty better men can not remedy. 

The relation between the nervous system and the menstrual 
function is also shown in this bit of clinical history. When the 
haemorrhage was suddenly checked the patient 
me^ruTwdons^ 6 na d a convulsion, and when the flow returned 
the convulsions ceased. Each time the dis- 
charge was lessened, the nervous twitchings and choreic move- 
ments became more manifest. And even when the convulsions 
were not induced by an arrest of the menses, these jerkings and 
twitchings were very troublesome and persistent. It really 
seemed as if the patient was " decreed " to have either the 
menstrual disorder or the convulsive affection. The problem 
in the treatment was how to cure the one without causing the 
other. 

You are aware that the liability to hysterical convulsions, 
spasms and paralysis, is limited to menstrual life. In girls, 
chorea, or St. Vitus' dance, subsides as pu- 
berty approaches, and finally disappears when 
the catamenial function is established. There is a form of men- 
strual mania that may accompany amenorrhoea, or menorrhagia, 
which, in many respects, resembles puerperal mania. All of 
which illustrates the intimate and profound relation between the 
menstrual function and the function of innervation. 

Another item that we should consider in this connection is the 
folly of supposing that, in certain cases of uterine haemorrhage, 
the disease is cured if we only stop the flow. 
There are cases of flooding in which if we fulfil 
this indication it is all that we can expect to accomplish, for in so 
doing we shall necessarily remove the cause of the trouble. Such 
cases are those in which the loss of blood depends upon the pres- 
ence of polypi, fibroids, hydatids, or of the 

A practical distinction. , . n 

placenta m utero, upon cauliflower excres- 
cence, or the more ordinary form of uterine cancer. These can 



MENORRHAGIA CONTINUED. 271 

frequently, and indeed generally be relieved most speedily and 
certainly by surgical, together with medical means. 

But in such cases as this, where the haemorrhage depends upon 
a pathological condition of the uterine mucous membrane, and a 
morbid state of the whole menstrual function, it will not suffice 
to check the discharge. For, even if the patient escapes having 
more alarming symptoms in consequence, the disease which has 
caused the flow is not cured thereby. The remedy must be pos- 
sessed of an intimate, curative relation to the lesion that under- 
lies and has occasioned this particular symptom, else it will do no 
permanent good. 

The digestive derangement was a very natural and almost neces- 
sary consequence of the menstrual disorder. And so also was the 
chloro-ana?mia. Nothing could be better adapted 
The gastric and chior- foi th . licf than the careful attention to the 

otic symptoms. 

diet and to the surroundings of the, patient. 
Fresh air and sunlight, acid fruits, a cheerful room, and pleasant 
society, were useful auxiliaries toward the cure. Indeed, as the 
result proved, nothing could have been more appropriate than the 
treatment adopted. The nitric acid was perhaps the only remedy 
capable of correcting the menstrual irregularity without aggravat- 
ing the nervous disorder, of intercepting the convulsive paroxysms, 
and of curing the alimentary derangement. But alone, it was not 
sufficient to effect a radical cure. 

SUDDEN SUPPRESSION OF MENORRHAGIA BY ASTRINGENTS THE CAUSE 
OF SUBSEQUENT ILLNESS. 

Case. — Mrs. E. desires relief from attacks of what has been 

diagnosticated as bilious colic, from which she has suffered at 
frequent periods for eight months. The paroxysms almost always 
come on at night, immediately upon retiring. For a week past 
they have returned every evening. The pain is referred to the 
epigastric region, and is described as sharp, cutting and colicky 
in its nature. It also intermits, and, when most severe, there is a 
slight inclination to vomit. The paroxysm generally lasts about 
an hour, during which time she cannot lie down, but must sit, 
upright in the bed. After the fit she sleeps, soundly, and, with 
the exception of a loss of appetite for breakfast, and occasional 
headache, is quite well next day. It sometimes happens that un- 
usual excitement or fatigue Avill induce a paroxysm in the day- 
time. This trouble is greatly aggravated at each menstrual period. 
At present, the menses recur regularly every four weeks. 

Prior to the commencement cf these attacks she had, for some 



27 z 



THE DISEASES OF WOMEN. 



months, suffered from too frequent and too profuse menstruation 
The flow returned every two or three weeks, and the loss of blood 
was sometimes extreme. To arrest the haemorrhage, her physician 
ordered vaginal injections of strong alum water. This expedient 
arrested the flow, but induced a severe attack of metritis, from 
which, in the hands of another physician, she barely recovered. 
The menstrual interval was subsequently extended to about four 
weeks, but the flow was still too profuse. All sorts of expedi- 
ents were tried to arrest it, but without effect, until the patient, 
becoming wearied with it, took the responsibility of resorting 
again to the alum injections. As soon as she did so, the exces- 
sive flow ceased, but in lieu of it she began to have these attacks 
of excruciating pain. During the eight months which have 
intervened she has had three other physicians, none of whom 
has succeeded in clearing up the diagnosis, or in curing the 
disease. 

The temptation to resort to astringents, topically and inter- 
nally, in case of haemorrhage, is a very strong one. This is espe- 
cially true in those forms of uterine haemorrhage 

Intra-uterine astringents. . _. 

which are connected with menstruation, lhe 
arguments against their indiscriminate employment are few and 
simple. In the first place, unless connected with abortion or labor 
at term, the excessive flow is symptomatic. In this case, to check 
it, and to arrest it by styptics, is not to cure the patient, but to 
complicate matters and make them worse instead of better. The 
more rational method would be to address our treatment, external 
or internal, or both, to the removal of the lesion, or condition 
upon which this flow depends. Take away the cause and the 
effect ceases. To strike this single symptom out of existence 
would be to lose time and work mischief. 

Again, a copious menstruation, like a free diuresis or diaphor- 
esis, may be critical, and in a sense salutary. It may represent a 
species of safety-valve which, for the welfare of 
crkic e a 1 ° rrhagia somedmes tne general organism, should not be too ab- 
ruptly closed. It is quite probable that the 
menstrual secretion is partly oliminative, and designed to expel 
certain noxious matters which would prove harmful if retained. 
To suppress the flow voluntarily might induce the very symptoms 
which are present in case of retention from diseased states, a con- 
sequence which it is our duty to avert. 

You will readily perceive that the sudden application of a solu- 



MENORRHAGIA — CONTINUED. 273 

tion of alum to the vascular mucous membrane of the superior 
vagina and uterine cervix, for the arrest of the 

Physiological argument ' 

against intra-uterine as- haemorrhage, would be verv apt so to derange 

tringents. . .,,.,. n 

its capillary circulation as to cause inflamma- 
tion. If you desired to produce an attack of metritis, no more 
certain and expeditious method could be devised. It is no marvel 
that this poor woman suffered greatly, and almost died in conse- 
quence of this unwarrantable expedient. Thousands of lives have 
been sacrificed in this very manner. These harsh astringents are 
often thrown into the vagina, and sometimes even into the womb 
itself, for the same purpose as in this case. With utter disregard 
of the delicacy of the structures involved, of the danger of inflam- 
mation and its sequela?, of the risk of throwing the fluid through 
the Fallopian tubes directly into the cavity of the peritoneum, of 
damming up the blood upon the ovaries, of pelvic hematocele, 
and other consequences a hundred fold more serious than the 
haemorrhage itself, this practice is still sanctioned by the profes- 
sion. I have brought this case before you, in order to impress 
upon your minds some of the possible consequences that may result 
from such treatment ; also to show you " a more excellent way." 
We shall doubtless have frequent occasion to refer to the reflex 
relations existing between the uterine cervix and the stomach. 
There is much that is curious and suggestive 

Digestive disorders from . . ,..,,. , 

vaginal and uterine injec- therein. But there is a clinical hint connected 



uons. 



with the history of cases like this, the signifi- 
cance of which you should appreciate. A large proportion of the 
cases in which astringent injections of various kinds have been 
thrown into the vagina, and thus brought into contact with the 
neck of the womb, are characterized by peculiar and inveterate 
disorders of the stomach and bowels. Some of the worst examples 
of gastric indigestion that I have ever treated were chargeable to 
vaginal injections that had been resorted to for the cure of leucor- 
rhcea. In other cases, the ill effects have been observed in the 
production of intestinal colic, dyspepsia, and constipation. 

Here the irritant is applied to the superior vagina and about the 
cervix. Through nervous sympathy the stomach and bowels are 
implicated. Their functions are deranged, and more or less of 
actual suffering is induced. Such a train of consequences is all 
the more certain and characteristic, if the drug with which the 

18 



274 THE DISEASES OF WOMEN. 

injection was medicated had also a specific relation to some por- 
tion of the intestinal tract. And, upon reflection, you will find 
that a majority of the substances used in this manner have such a 
relation to the alimentary system especially. It is true of tannin, 
alum, the acetate of lead, the salts of silver, of copper, and of iron, 
the oil of turpentine, and many other remedies which have been 
used in this way. This explains the possibility that our patient 
first experienced her attacks of " bilious colic," falsely so-called, 
in consequence of the alum injections, which had been taken to 
suppress the haemorrhage from the womb. 

But there is another item which we must not pass over in 
silence. I allude to the fact that menorrhagia sometimes 
depends upon the presence of uterine polypi, 
^ Menorrhagia from polypi, w hich, being very vascular, occasion the in- 
creased and prolonged haemorrhage at each men- 
strual period. And not only so, but they sometimes cause a spe- 
cies of menstrual colic, which greatly torments the patient. I have 
repeatedly had occasion to witness the most extreme suffering, 
sometimes gastric, again gastro-intestinal, or perhaps uterine 
chiefly, which was entirely due to the presence and pressure of a 
polypoid growth within and upon the cervix. Indeed, when I 
find a patient complaining of these symptoms, and learn that she 
has not been in the habit of taking vaginal objections, I am suspi- 
cious of the existence of some intra-uterine growth, which may be 
sufficient to account both for the menorrhagia and the spasmodic 
colic. And I recommend you, gentlemen, to be upon your guard 
in all cases of this kind. Do not trust too exclusively to objec- 
tive symptoms, which might mislead you, and bring down reproach 
upon your school and your skill. Examine the case thoroughly, 
and do not forget the practical hints of which I have just spoken. 

Treatment. — This is a case of neuralgia of the coeliac plexus, 
induced by the alum injections. How shall we treat it? Is it 
worth while trying to antidote the poison thus introduced, when so 
long a time has elapsed since it was taken ? Or shall we prescribe 
for the symptoms as we find them ? This is a point upon which 
doctors would assuredly disagree. My own opinion is that, if the 
attack were more recent in its origin, and we had a reliable anti- 
dote for the toxical effects of alumina, the " chemical treatment,'' 
as it is called, might promise good results. But, under the cir- 



VICARIOUS MENSTRUATION. 275 

cumstances, we must base our prescription upon present indica- 
tions. 

The character of the pain, the period of its recurrence, the 
causes that induce it incidentally, and the aggravation at the men- 
strual period, are the prominent and most significant symptoms. 
Pulsatilla is the remedy. I recommend .that she take a dose of it 
every three hours during the day. If the paroxysm returns at 
evening, it may be repeated every twenty or thirty minutes until 
the attack has passed. When the symptoms are relieved, the med- 
icine may be given at longer intervals. I have sometimes cured 
this species of neuralgic colic, dependent upon maltreatment of 
uterine affections, by giving a few doses of atropine 3d, and again 
with colocynth of the same potency. 

There are cases of reflex disorders in other organs, as for exam- 
ple the stomach and bowels, the head, the heart, and the general 
nervous system, but more especially in the ova- 
intolerance of vaginal r i es t hat will not yield to the best chosen rem- 

injections. * «/ 

edies until the habit of taking vaginal injections 
is proscribed. This remark applies not only to injections that 
are harsh and decidedly irritant, but also to such as are ordinarily 
harmless. These cases are exceptional, and should not tempt you 
into an indiscriminate denial of the efficacy of such means under 
proper indications. It will be best for this patient not to take any 
kind of vaginal injection until she has recovered her health, and 
then only for the purpose of cleanliness. 

Should these means fail, it would be proper to proceed upon the 
hunt which I have given you concerning the possibility that there 
is a foreign body, a polypus, within the womb. The os should be 
so dilated with a sponge or other tents, that the proper exploration 
oan be made. This should be done slowly and carefully, in the 
manner which will be detailed when I come to speak of the treat- 
ment of uterine polypi. 

VICARIOUS MENSTRUATION. 

Case. — Sarah A., 19 years of age, unmarried, presents herself 
for the first time at the Clinic. " How long have you been ill?" 
"Four months, sir." "Of what do you complain?" "I have 
very frequent spells of coughing, and sometimes have the nose- 
bleed." " Is the cough dry or moist? " "It is dry and hard, and 



276 THE DISEASES OF WOMEN. 

I sometimes have pain in my chest." " Do you ever raise blood? '* 
"No, sir." "How long have you suffered from the cough?" 
" Four months." " And the nose-bleed? " " For the same time, 
sir." " Were you subject to a cough before that time? " " Never, 
sir." " Have you been sick in bed with it? " " No, sir." " How 
often do you have your nose-bleed? " " Exactly once a month." 
" It comes very regular, does it? " " Yes, sir." ' ' How long does 
the attack last?" " I have it off and on for about three or four 
days." " And then it goes away and does not return at all for 
another month?" "It does, sir." "Is the cough worse at the 
same time?" " Yes, sir." "That will do; you may step into 
the next room for a few moments." 

These symptoms are suspicious and suggestive. The attention is 
at once drawn to the periodical nature of her complaint. The ex- 
perienced physician will recognize the menstrual function as the 
one most likely to be at fault. If with these symptoms he finds 
the menses have been suppressed, that there is amenorrhcea as a 
concomitant, the diagnosis is easily made out, for, in that case, 
the patient has what is termed vicarious menstruation. 

I have questioned this young woman, privately, and learned 
that for four months she has not menstruated at all. Prior to that 
time she reports herself as having been quite "regular." Upon 
further inquiry I have also satisfied myself that she is not preg- 
nant. This is an important point in all oases of suppression. 
Epistaxis may occur in plethoric persons, in the early months of 
pregnancy. 

When a flow of blood is established from some other part than 
the uterus, and that flow recurs with all the regularity of the cat- 
amenial discharge, and really supercedes it, we call it vicarious 
menstruation. This haemorrhage may take place from the intes- 
tinal or pulmonary mucous membranes, or the skin. Thus there 
may be critical haematemesis, or haemoptysis, epistaxis, or haem- 
orrhage from the eyes, ears, axillae, anus, bladder, the rectum, the 
ends of the fingers and toes, from thestump ol an amputated limb, 
or from an ulcer. Usually, however, the vicarious flow comes 
from a weak and vulnerable organ or surface. Thus our patient 
is of scrofulous habit, narrow-chested, with manifest tubercular 
tendencies. The respiratory mucous membrane is delicate and 
susceptible. The sudden suppression of an accustomed discharge 
from the generative intestine imperils the textural integrity of 



VICARIOUS MENSTRUATION. 277 

this membrane. You are perhaps aware that there is a close sym- 
pathy of function between the internal generative organs and the 
lungs. Respiration and ovulation are intimately related. It fre- 
quently happens that the first alarming symptom of incipient 
phthisis will be a suppression of the menses, and consequent 
pectoral irritation. 

Now the Schneiderian membrane belongs to the respiratory sys- 
tem. The epis taxis and the cough, of which you have heard this 
woman complain, are referable to menstrual suppression. This 
suppression is abnormal, and consequently the remote symptoms 
are pathological. If it resulted from pregnancy the case would 
be different. Then the cause being physiological, the system 
would accommodate itself to the new order of things, and harm 
would not necessarily result. 

As it is, we must restore the natural flow and relieve the sup- 
pression, or serious consequences will certainly befall the pulmo- 
nary system. 

Treatment. — The indications are manifest. It is not important 
a,s in the former case, to prescribe any especial treatment for the 
haemorrhage. A more important work is to be accomplished. The 
principle function in the female economy is suspended. There is 
no compensating relation between the uterine and the respiratory 
mucous membranes, as between the skin and the kidneys, whereby 
the duties of the one may temporarily be imposed upon the other. 
This condition of things is extra physiological and hazardous, and 
must not be permitted to continue. 

The normal stimulus of functional activity in the ovaries and 
uterus becomes a morbid irritant when directed to the lun^s. We 
must restore the conditions to functional order in the generative 
system ; not by emmenagogues, that would compel a sanguineous 
flow from the uterus, but by agencies designed to harmonize the 
delicate sympathies now discordant. Our remedies must be directed 
not only to the original disease of the uterus and its appendages, 
but especially adapted also, to the present disordered condition of 
the lungs and their appendages. The pathogenesis of several of 
our more prominent remedies represents various shades of sympa- 
thetic relation between these two very important functions.* 
Calcarea carb., pulsatilla, calcarea phos., natrum mur., sangu- 
naria can., alumina, kali carb., ferrum acet., and possibly also ; 



278 THE DISEASES OF WOMEN. 

caulophyllum, and hamamelis. I recommend yoa to devote your 
attention to this important therapeutical question. Many physi- 
cians employ these remedies unwittingly for the relief of objective 
symptoms dependent upon menstrual disorder, without any idea 
whatever of their significance. 

Pulsatilla is adapted to this patient's temperament and disposi- 
tion, as well as to the usual pectoral and uterine symptoms pre- 
sented in her case. We accordingly prescribe it for her in the 
third decimal attenuation, a dose to be taken three times daily. 
This should be continued at lengthened intervals throughout the 
inter-menstrual period. If she is not improved thereby, the 
calcarea phos. may be of service. 

Of late serious doubts have been expressed concerning the 
genuineness of vicarious menstruation. Dr. Robert Barnes pre- 
sented a paper to the British Gynecological Society last year 
in support of the old view that such cases did really occur, 
but the idea was combatted by Drs. Wilks and others. A proposal 
growing out of the discussion was that this "analogy of menstrua- 
tion" should properly be styled a vicarious hemorrhage.* 

*The British Gynecological Journal, 1886, pp. 151-188. 



Part Fourth. 



THE DISEASES OF PREGNANCY. 



LECTURE XVII. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 

The Diagnosis of Pregnancy. False Conception. Case.— Excessive abdominal develop- 
ment in Pregnancy. Case.— The size of the abdomen as a sign and sequence of preg- 
nancy. Pulsatilla in mal-presentations. 

Case. — Mrs. , aged 39, has not menstruated within the last 

fourteen months. About the time the menses ceased she had a 
severe attack of dysentery, which continued four weeks. This 
was accompanied and followed by evident inflammation of the 
bladder, the vagina, and possibly, also the womb, from which 
she convalesced very slowly. Five months and a half later, she 
married. Her husband remained with her only two days, and then 
left on plea of business in a distant State. In that period only 
two attempts were made at coitus, in neither of which did the male 
organ penetrate the vagina. She suffered extreme agony in these 
ineffectual attempts at intercourse. 

During the interval, which is now eight and a half months, the 
husband has never returned. Four months ago she observed that 
the form of her abdomen began to change, becoming more and 
more prominent in the left inguinal and hypogastric regions. 
Sometimes the tumor subsides ccnsiderably, and afterwards be- 
comes as large as before. The only unusual sensation she has 
experienced was that resembling the gurgling of a liquid, which 
seemed to pass upwards from the left hypochondrium toward the 
umbilicus. The abdomen is now as large as that of one who is 
eight and a half months advanced in pregnancy, but the chief en- 
largement is upon the left side. She has had no morning sickness, 
no caprice of appetite, no urinary trouble, and no headache since 
she incurred the risk of becoming pregnant. The breasts are 
somewhat enlarged and tender, and the areola about the nipple is 
quite distinct. Physicial examination of the abdomen by auscul- 
tation reveals a sound resembling the placental souffle, but it is 
not very decided. We have failed, after several examinations, to 
detect the foetal heart-sounds. 



280 THE DISEASES OF WOMEN. 

Although the whole generative function is physiological, and 

does not necessarily include any morbid process whatever, still its 

contingencies are so numerous, and the changes 

Its great importance. . ° 

which it develops within the pelvic and ab- 
dominal organs or so pronounced, and withal so similar to those 
which attend upon certain diseases, as to render the diagnosis of 
pregnancy a very delicate and difficult matter. It may involve 
the position of your patient, and others also, in society and in the 
church, loyalty to the marriage relation, and legitimacy of off- 
spring, as well as questions which are purely professional in their 
character, and which concern the proper treatment of the case in 
hand. How to decide whether a woman is or is not pregnant, is 
one of the lessons which you should learn most thoroughly. For 
nothing would so damage your reputation, as skillful practitioners, 
as to decide it wrongly. 

In many respects the case before you is a very interesting one. 
The menses have been suppressed tor a long period. And, al- 
though women sometimes reach the climacteric 

Suppression of the ^ f their fortieth year there fe reason to be _ 

menses. d 7 

lieve that we should not attribute the arrest of 
function in her case to this cause. If there was no uterine tumor, 
no development of the abdomen, and none of the other signs 
of pregnancy were present, we might, perhaps, charge 
the suppression of the accustomed flow to "change of life." If 
she had not suffered from disease of the pelvic organs, and the sup- 
pression had not already existed before her marriage, the case 
would be different. As it is, we must remember that many other 
causes beside conception may interrupt the regularity of the men- 
strual function. Inflammation of any portion of the generative 
intestine, the vagina, the uterus, the Fallopian tubes, or of the 
ovaries, may cause an amenorrhoea which shall lead us to suppose 
a woman to be pregnant. So also inflammation of the bladder, 
the rectum, the intestines, and even of the lungs, may have the 
same effect, directly or indirectly. Displacements and deviations 
of the womb sometimes arrest the flow by obliterating the canal 
of the uterine cervix. The presence of polypi, fibroids, hydatids, 
and other tumors within that organ, may have the same mechani- 
cal effect. Atresia of the cervix, in consequence of the use of harsh 
astringent injections, or of the application of caustics, or of in- 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 281 

Hammation caused by an improper or ill-adjusted pessary, or of the 
bungling and harmful use of instruments in abortus or in labor at 
term, may also cause a suppression of the menses. 

Therefore, while this symptom is regarded by women themselves 

as an almost certain sign of pregnancy, physicians look upon it as 

equivocal, and not by any means positive. We 

An uncertain sign. , ... . ,_,, . 

can not rely upon it m a given case, lliis woman 
has not menstruated for fourteen months. The period during which 
the arrest has continued is longer than that proper to gestation. 
Shall we therefore conclude that she is not pregnant, because she 
lias passed the ninth month without being delivered of a child? 
That would not be a safe or satisfactory conclusion. For, in some 
cases, the catamenia are arrested for weeks and even for months, 
and conception takes place before they have been restored. This 
often happens with women who become pregnant again while they 
are nursing their children, and before they have begun to men- 
struate after delivery. So our patient might have had a suppres- 
sion of this flow for six months or more, and then have become 
pregnant after her marriage, and before the menses had re-ap- 
peared. 

With respect to this symptom, therefore, there are so many 
irregularities, complications and exceptions that it is not to be 
regarded as a positive sign of pregnancy. At best, it is only cor- 
roborative. Taken in connection with other symptoms, it may 
help to settle the diagnosis, but singly and alone it is of very little 
consequence. An additional reason why we should not place an 
exclusive dependence upon it is that we are always compelled to 
take the patient's version of the facts in the case. If she is anxious 
to have children, or, for any ulterior reason, desires to have it de- 
cided that she is pregnant, she may claim that for a given time 
she has not menstruated at all, when this is not so. Or if, on the 
other hand, she is disposed to mislead the doctor, she may insist 
that her courses are regular, and normal in every respect, when 
in truth, they have not appeared for months. 

It is the habit of some physicians to prescribe marriage as a 

remedy for suppression of the menses, with al- 

Mamage as a remedy most a tota i disregard of its cause, and of the 

ior suppression. . , . . T . 

consequences of taking such advice. It is my 
duty to warn you against this practice. For it is altogether 



28% THE DISEASES OF WOMEN. 

wrong. Thousands of persons have been made wretched, while 
few, very few, have been cured by it. 

In pregnancy it is not at all uncommon for the abdomen to be 

developed upon one side more than upon the other. Usually, 

however the uterine tumor inclines to the right 

Uterine obliquities. . 1 V ■ . ... .. . . , 

hypochondnum, for the alleged reason that the 
rectum pushes it in that direction as the womb passes above the 
superior strait at or about the fourth month. In this case how- 
ever, the tumor is at the left side, and has been from the first (left 
lateral obliquity). Its size and prominence, according to the 
patient's story, appear to vary somewhat, a fact which is easily 
enough explained upon the theory that there is an accompanying 
meteorism of the abdomen, which subsides of itself and recurs 
again. This would also account for the gurgling sensation, 
which is incidental, and not, in any sense, distinctive of preg- 
nancy. 

We need not discuss the negative value of the absence of morn- 
ing sickness, nausea, caprice of appetite, quickening, headache, 
toothache, vesical tenesmus, and other occasional symptoms of 
pregnancy. In many examples of gestation, they are wanting alto- 
gether from first to last. If she has really passed the eight mouth, 
ballottement would not be available. 

But the changes in the areola about the nipples, and in the 

breasts themselves, are more significant. In pregnancy, whatever 

changes take place in these glands affect both 

Changes in the breast. . ... ,„, . . ,. .. 

breasts alike. I his is not true of any disease 
to which they are subject. Consequently, when you find that both 
these organs are becoming larger, warmer, and softer, especially in 
those who have not already borne children, or been pregnant be- 
fore, or if there is a slight secretion of milk, it is a suspicious sign 
of pregnancy. More especially is this true if the nipple is more 
erectile, vascular, and granular on its exterior and tip than it has 
been, and if the circle of discoloration about it is more pronounced 
and decided. Here you have a good illustration of this subject. 
You observe the glandular follicles about the nipples are consider- 
ably enlarged, and that they pour out a quantity of fluid which 
gives the areola the appearance of having been oiled. The cellu- 
lar tissue beneath and within the nipple is in a state of turgescence. 
The discoloration about the nipple is so marked that you can see it 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 283 

across the lecture-room. This looks as if our patient were really 
pregnant, and some authorities would decide the question upon the 
evidence afforded by this single symptom. But we must look a 
little further. 

If we could detect the foetal heart-sound, resembling the tick- 
ing of a watch beneath the pillow, we should have a positive and 
unmistakable sign of pregnancy. But this we 

The foetal heart-sound. . „ ., , , ,. ., . , , ., , 

have tailed to elicit. And yet it may be pres- 
ent. The mere fact that we fail to detect it, is no sign that a 
woman is not pregnant; while, if it can be heard, we know that 
she is enceinte. It is not safe, however, to depend upon a single 
examination in a case of this kind. For you may imagine that 
you hear it when you do not, or it may be impossible to hear it 
to-day, and the easiest thing in the world to note it to-morrow. 

The uterine souffle is so frequent an accompaniment of ob- 
dominal and uterine tumors, aneurism, etc , as not to afford any 

reliable criterion of the pregnant state. At best 

The uterine souffle. .. , n . . ..., , 

it is only a confirmatory sign, which may be 
classed as a probable, but not as a positive symptom of pregnancy. 
There is still another means of exploration that, in a case so ad- 
vanced as the one before us, may help to settle the diagnosis of 
pregnancy. If this woman really conceived 
eisfht and a-half months ao;o, the changes which 
have taken place in the uterine cervix should be quite marked 
and decisive. And so I find them to be. The neck of the womb 
is shortened and almost obliterated, soft, somewhat patulous — 
although she is a primipara — and in such a condition as can only 
attend upon gestation. 

This, therefore, enables us to decide that Mrs. is undoubt- 
edly pregnant. In reaching this conclusion, we may rely upon the 
changes in the breast, the discoloration of the areola, the char- 
acteristic softening and shortening of the cervix uteri, the abdom- 
inal development, and the placental souffle. All of these symp- 
toms are taken collectively, and within the space of a month, at 
least, I have no doubt but that our diagnosis will be confirmed, 
(Exit the patient.) 

Some of you may have doubted the possibility of conception 
without penetration of the male organ during coitus. Numerous 
cases are recorded in which this result has followed imperfect in- 



284 THE DISEASES OF WOMEN. 

tercourse on account of some mechanical obstacle, as an imperfo- 
rate hymen, or an inveterate vaginismus, and the like. In resolv- 
ing such doubts you have only to remember that the essential 
condition of impregnation, is that the vitalizing part of the male 
semen shall be brought into contact with the ovum of the female 
somewhere within the generative tract. The discharge of that 
semen within the vulva may under certain circumstances and ex- 
ceptionally, produce the same result that would follow the com- 
plete act. But such cases are by no means so frequent as some 
have imagined. 

MOLAR PREGNANCY — FALSE CONCEPTION. 

In my obstetrical course you were told that, in forming a cor- 
rect diagnosis of pregnancy, an exclusive reliance upon any of its 
presumptive or of its probable signs would be likely to mislead 
you. 

Case. — Mrs. W , aged 42, was married eight months ago. 

She was at that time a widow; but had never had any children. 
She says that within the eight months, or since her last marriage, 
she has not menstruated. Prior to that, menstruation was normal 
in every respect. She has had no vicarious haemorrhage, or leu- 
corrhceal flow. When the menses ceased she began to have 
morning-sickness, which continued for six weeks. She had also 
various caprices of the appetite, with faintness before dinner, and 
inordinate craving tor food. There was no perceptible develop- 
ment of the ovum, or enlargement of the abdomen. The mamma? 
became swollen and sensitive. 

Six days ago, after walking to church, upon the icy pavement, 
she began to "flow." The hemorrhage from the uterus was pas- 
sive, irregular, and slight, until the third night, when, after having 
had a great deal of pain about the back and loins, with some head- 
ache and debility, she awakened out of sleep very much fright- 
ened by the escape of a fleshy mass from the uterus and vagina. 
The flowing soon ceased, and to-day she has ventured to walk to 
the Clinique. In addition to the details already given, she says 
that all her unpleasant and indiscribable feelings about the hips and 
abdomen were greatly relieved by a bandage worn tightly about 
those parts. 

This was an example of spurious pregnancy, sometimes styled 
false conception, pseudo-preo-nancy, quasi-g-es- 

Morbid anatomy. / / -, T , ,, G 

tation, molar gestation, and should not be con- 
founded with pseudo-cyesis. The product was a fleshy mole, which 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 285 

the patient has preserved, and brought with her, and which we 
will now proceed to examine. Fortunately for us, she has kept it 
in water, and the examination will not be difficult. You will ob- 
serve that the mass is about the size of a small lemon. On cutting 
through its walls, we come down to the amnion, which is intact. 
Slitting this open, a slight flow of its proper liquor escapes. Here 
is the rudimentary embryo, which, although it has been eight 
months in utero, is not larger than it should have been at the 
sixth week of pregnancy. The undeveloped funis is but a mere 
thread, and ragged at its free extremity. Between the outer 
membranes, or rather within the thickened wall outside of the 
amnion, blood has been effused, and small coagula are seen. 

These appearances indicate an arrest of embryonic develop- 
ment. Conception probably took place as it should have done, and 
all went on well for a limited period. But, for 

Death of the embryo. 1 . . 

some unknown reason, the nourishing supplies 
that were derived from the uterine surface, and designed for the 
ovum, were appropriated to the abnormal, pathological growth of 
the chorion. The little embryo was therefore sacrificed. It died 
from a lack of those elements which were necessary to the devel- 
opment and repair of its tissues, and the hypertrophied chorion 
and decidua constitute this carneous or fleshy mass which is called 
a mole. 

Although women of all ages are liable to this form of spurious 
pregnancy, yet it is a singular fact, that those who have reached 
their fortieth year seem more prone to it than 
those who are younger. As in the case before 
us, it is not uncommon among women who marry a second time 
late in life. The formation of these moles (which are the conse- 
quence, not the cause, of the death of the ovum) is intimately 
connected with the history of abortion. Rigby says most expres- 
sively : " When any cause has occurred to destroy the life of the 
embryo, during the early weeks of pregnancy, one of two results 
follows, either that expulsion takes place sooner or later, or the 
membranes of the ovum become remarkably changed, and con- 
tinue to grow for some time longer, until at length they form a 
fleshy, fibrous mass, called a mole, or false conception." 

The true mole is always a product of conception. When the 
mass has been expelled, it is not difficult to recognize it, and to 



286 THE DISEASES OF WOMEN. 

separate it from spurious formations which resemble it in some re- 
spects, by the presence of a rudimentary embryo 

Retention of embryo. tpt ,, , 

withm its cavity. li, however, the embryo 
died during the first month, it may have been dissolved, and we 
shall, therefore, fail to find it on dissection. Such a mole may be 
retained within the uterus for many months, or it may be cast off 
and expelled at or about the period at which the menses should 
have returned had the woman not been pregnant. It sometimes 
happens that the haemorrhage attendant upon labor of this kind 
is profuse and long-continued. Generally, however, it ceases with 
the delivery of the fleshy mass. Ambrose Pare cites a case in 
which a mole was retained in the womb for seventeen years. 

Among the clinical points worthy of note in the case before us, 
you will observe that, until her last marriage, this woman's men- 
struation was habitually regular and healthy. 
me^strua^on nancy and ^ * s important to take this fact into account, 
for it sometimes happens that menstrual disor- 
ders predispose to abnormal developments of the membranes 
which enclose the ovum. Membranous dysmenorrhea may indi- 
rectly cause this form of spurious pregnancy. 

Following the arrest of the catamenia there was no vicarious 
discharge. Morning sickness set in, and our patient was sup- 
posed to be pregnant. This continued for six 
nanc° bableslsnsofpreg " wee ks, or most probably until the death of the 
embryo, and was accompanied by the capricious 
appetite, fainting, etc., to which so many women are liable after 
conception. 

For the best of reasons there was no observable change in the 
abdomen. The usual development of the uterine tumor was pre- 
vented. There was no necessity for the womb to ascend out of 
the pelvis, as it would have done had gestation gone on properly. 
The embryo was dead, and its growth became impossible. The 
uterine cavity was already large enough to contain it, and hence 
there was no need of its further expansion. If the case had been 
one of hydatids (falsely so-called), the abdominal enlargement 
might have taken place. For these hydatigenous growths some 
times fill the womb, and cause it to enlarge in very much the 
same manner as if it contained a healthy foetus. They may also 
be retained even some months beyond "term" before they are 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 287 

finally expelled. You should not forget that these uterine hyda- 
tids are really due to a defective organization of the placenta, or, 
more properly speaking, to a cystic degeneration of the villi of the 
chorion. 

We have no means of knowing the precise changes that took 
place in the breasts in this case. It is possible that the areolae 
may have been discolored, and the follicles about the nipples de- 
veloped, as in true pregnancy. These glands are liable to become 
swollen and sensitive from other causes, and this general symp- 
tom of pregnancy would therefore be very uncertain and unreli- 
able. At this time there is nothing peculiar in the appearance of 
the mammary glands. Usually, in similar cases, the series of 
changes proper to these organs, and which provides for the extra- 
uterine needs of the infant, is arrested when, from any cause, the 
embryo dies. Even when the mole or the hydatid mass is carried 
to the ninth month, or beyond, before it is extruded, there is gen- 
erally little or no secretion of milk. 

From these remarks you will infer that, although the suppres- 
sion of the menses, the morning sickness, and the fickleness of 
appetite, are to be regarded as presumptive 

These signs do not indi- . - . -. f « , , 

«ate the progress of preg- signs oi conception, and may signify that the 
fecundated ovum has reached the uterine cav- 
ity, and commenced to develop therein, still they do not afford a 
certain criterion of the progress of gestation. They may have 
marked its commencement ; but do not indicate its possible arrest 
or failure. This patient had the morning sickness during the 
first six weeks, but afterwards the only remaining symptom of 
pregnancy was the non-appearance of the menses. And the pro- 
longed arrest of this flow is to be accounted for by the presence 
of this foreign body, or mole, within the womb. 

Concerning the final cause of labor in this form of pseudo-preg- 
nancy, various theories have been advanced. Perhaps the most 
reasonable is that which refers it to the men- 

Cause of the delivery. - .. , , r • t '■ - t pn /» 

strual cycle, when the physiological afflux oi 
blood to the uterine, mucous membrane facilitates, if it does not 
actually insure, the entire separation of the decidua. At this par- 
ticular period the cervix uteri is also more or less relaxed, as if 
menstruation were coming on, and some slight exciting cause, as, 
for example, a fall, or sudden shock, or forcible exercise, as in 



288 THE DISEASES OF WOMEN. 

walking on an icy pavement, may percipitate labor. Dilating 
pains follow or accompany the haemorrhage. In due time expul- 
sive contractions set in, and the womb is emptied of its contents. 
The suffering may be either slight or severe, its quality and 
degree varying with the laxity of fibre ot the uterine neck, the 
rapidity of the labor, the size of the mole, and the temperament 
of the patient. It is only in exceptional cases that the mass drops 
away with so little pain as this patient had. Although there are 
women who frequently and habitually suffer from this form of 
spurious pregnancy, it does not follow that one such mishap is 
certain to be succeeded by a second of a similar kind. Even at 
her age, Mrs. W. might, perhaps, pass through another pregnancy 
successfully. 

In every case of this kind it is of great importance carefully to 
examine the mass that has been expelled. For this purpose it 
should first be soaked in water for two or more hours, and then 
cut open so as to reveal its internal structure. 

EXCESSIVE ABDOMINAL DEVELOPMENT IN PREGNANCY. 

It sometimes happens that symptoms which are analogous to 
those afforded by the patient who has just left the room, depend 
on other causes than those already named. Only yesterday I waa 
consulted by letter in a case of this kind. My patient writes: 

Case. — I had called myself seven months advanced in pregnancy,, 
but many things conspire to make me think it probable that I am 
at least eight months along. I am exceedingly large, and from my 
extreme size, suffer greatly from faintness. For a fortnight I have 
endured severe pain in my left side, which nothing will relieve, 
although sitting up aggravates it. It has become almost unbear- 
able, wearing my life and strength away, and giving me no rest, 
day or night. 

" My little ones have always been large, weighing tenor eleven 
pounds, and you know I am a wee bit of a woman. But now the 
doctor thinks it probable that there may be two of them, which 
are small but amazingly strong and active, while there is evidently 
a great quantity of water contained in the womb. The child was 
in such a position as to cause much suffering and uneasiness, it 
being apparently across the pelvis. The doctor gave me pulsatilla, 
and whether it produced the effect or not, one week later it was 
pronounced ' all right.' 

" Will you be so kind as to inform me if there is anything that 
will relieve this pain in my side? If it should continue, would it 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 289 

not be well to hasten delivery, before I am altogether worn out ? 
I frequently have severe and almost unbearable contractions, 
which cause the abdomen to feel as if turned into stone." 

This case presents several points of practical interest. As you 
will observe, it supplies additional details, and is an excellent 
appendix to the former one. Gestation is more advanced, and 
the symptoms are different. 

During pregnancy the size of the abdomen is relative. There 

is no actual scale of measurement or development for all, or even 

for single patients, who are successively preg- 

Size of the abdomen as a . . 

sign and sequence of preg- nant. Hence the absolute impossibility 01 

nancy. 

judging by this sign whether a woman is in the 
seventh or eighth month. The abdomen is proportionally larger 
in short than in tall women, in multiparas than in primiparse, in 
those who are pregnant with twins than in case the womb con- 
tains but a single foetus. Its prominence varies with the laxity 
of the abdominal walls, the position of the uterus, the size of the 
foetus, and possibly its position, and with the quantity of amniotic 
liquor that surrounds the child or children. It may also become 
very large from intestinal indigestion and tympanites, abdominal 
dropsy, uterine or ovarian tumors, and malformation or dropsy of 
the foetus. 

Whatever their cause, these symptoms give rise to suffering 
and apprehension. They convert a natural process into a species 
of martyrdom, which, luckily, is self-limited. 

Diagnosis. — You will sometimes find it extremely difficult., and, 
indeed, quite impossible, to determine the cause or causes of these 
symptoms and the lesions, functional and organic, of which they 
are the token. A pendulous belly, with undue size of the abdom- 
inal tumor, occurs more frequently in spare, ill-conditioned women 
than in those who are short, plump, and well nourished. The mus- 
cles are thin and flabby, and the patient is more or less anaemic. 

If the extraordinary size depends on the position of the uterus, 
that organ will be found to incline forwards, over the pubes, or to 
one or the other side of the abdomen — usually to the right side. 
If upon the size of the child, its outline can be felt through the 
abdominal walls. Note should also be taken of the size and 
weight of former children, if the patient has ever been pregnant 
before. The chances are that, having always had very large child- 

19 



290 THE DISEASES OF WOMEX. 

ren, my correspondent is carrying one now, and that most of her 
symptoms are referable to this fact. Women who have had child- 
ren that weighed nine pounds and over, very rarely have twins 
in a subsequent pregnancy.* 

The position of the foetus in utero would be more apt to modify 
the shape than the size of the tumor. The position of the child 
is so frequently changed, even up to the time that labor com- 
mences, that a constant and uniform increase in the size of the 
abdomen could hardly depend on this cause. 

The characteristic symptoms by which you would recognize an 
extraordinary enlargement of the abdomen, dependent on dropsy 
of the amnion, are the following. It is an acute affection, the 
tumor is circumscribed, disproportionate, is developed rapidly, 
and is most likely to occur in those who have previously had, or 
at the time are having, dropsy elsewhere. It almost never occurs 
in those who are not of a dropsical diathesis. To the hand, when 
placed upon the abdomen, the movements of the foetus seem dis- 
tant and indistinct. The foetus is almost always small, feeble, and 
illy-developed, and generally survives its birth but a short time. 
The tumor may develop to such an extent as to occasion the most 
alarming dyspnoea and syncope, by pressing upon the diaphragm 
and adjacent viscera. 

Intestinal disorder may produce an excessive enlargement of 
the abdomen in pregnant women, either by causing dropsy of the 
peritoneum, or by the inflation of the bowels with gas. In the 
former case the hepatic function is almost always implicated. In 
the latter the intestinal glandular apparatus. The symptoms 
would vary, and you would not fail to recognize them. 

Uterine and ovarian tumors would have a history that com- 
menced before pregnancy. Neither mal -formation, nor hydro- 
cephalus, nor general anasarca of the foetus, could be diagnosti- 
cated with certainty prior to delivery. Twin pregnancy might be 
detected through the foetal heart sounds. 

Prognosis. — It is an exceptional case for any woman to pass 
through the state of pregnancy, from beginning to end, without 
complaining of these or analogous symptoms. And, strange to 
;say, the rule appears to be that, with certain qualifications, those 
who are most prone to these sufferings are least liable to have 

* At birth this patient's child weighed eleven pounds. 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 291 

difficult labors, or tedious and dangerous convalescence in their 
lying-in. The chief danger from any of these symptoms, at what- 
ever period of gestation they may occur, is from abortion. If you 
can avert this calamity, the patient will probably do well. The 
greater the perturbation of the nervous system, or the more the 
urinary and hepatic functions are deranged, the more decidedly 
this unfortunate result is threatened. Dropsy of the amnion is 
more fatal to the child than to the mother. In all cases you 
should inspire your patient with courage, and with the hope that 
all ma}' yet be well. A lugubrious, long-faced doctor would 
always be an additional affliction to her, but especially under 
these circumstances. 

Treatment. — The general indication is to make the woman as 
comfortable as possible, to turn aside the contingencies that 
threaten miscarriage, and to bring her through to term as quietly 
and safely as we may. To this end the directions which I gave 
you in my remarks upon the case that preceded this are equally 
appropriate here. 

The remedies indicated will vary with the special pathology of 
the case, or as the phrase is, with the symptoms presented. If 
the enlargement is due to abdominal or to amniotic drops}', those 
remedies would be called for which are suited to the dropsical 
diathesis, and you would select from among them that one which 
is most appropriate to the symptoms of each individual case. I 
should caution you, however, against prescribing the apis mellifica 
in a low potency in case of dropsy of the amnion, lest it should 
precipitate a miscarriage. 

Incidental disorders of the intestinal tract suggest their own 
remedies, among the more prominent of which are arsenicum, 
chamomilla, nux vomica, mercurius, china, colocynth, belladonna, 
and veratrum. 

The pressure from a misplaced gravid uterus may sometimes be 
greatly relieved by a change of position on the part of the patient. 
Or bandages and supports, if properly adjusted, may tend to make 
life more tolerable, by allowing the patient to move around and 
to take exercise. They may also be made to add to the strength 
of the abdominal walls in case the child is preternaturally devel- 
oped, or where there are twins. 

I think that the induction of premature labor would not be jus- 



292 THE DISEASES OF WOMEN. 

tifiable in a case of this kind, unless the patient were in imminent 
danger from suffocation by dropsy of the am- 
tu^ h ilbof uctionofprema " n i° n ' I can imagine, although I have never 
met with such an example in practice, that this 
expedient might be necessary as often, perhaps, as once in a thou- 
sand cases. Be sure you do not resort to it, gentlemen, on your 
patient's prescription instead of your own. 

Concerning the alleged power of pulsatilla to correct a mal- 
presentation of the foetus at any period of gestation, or in labor at 
term, I am wholly skeptical. Up to this date 
S entat'onl! ainmal " pre " (Feb., 1887) there is not a single case on record 
which clearly proves it to be possessed of any 
such properties. In every published instance the testimony is as 
invalid and fallacious as in that which we have just had undei' 
review. This patient's physician was not certain in his diagnosis. 
First he said she had twins, then dropsy of the amnion, and finally 
the (one) child was " apparently across the pelvis." Pulsatilla 
was given, a spontaneous change followed — as has probably hap- 
pened with every foetus from the time of Cain until now — and 
the result was accredited to the remedy that had been swallowed ! 
Such things may not be impossible, but they are exceedingly 
improbable. 

The Newer Signs of Pregnancy. — Hegar's new sign of preg- 
nancy is available as early as the sixth week. It 
Hegar's^sigTi of preg- consists in recognizing by the bi-manual touch, 
the peculiar form of the uterus, which depends 
upon the growth of its body without any change in the cervix 
before the close of the second month. This shape of the organ 
resembles that of "an old-fashioned fat-bellied jug." 

Tait's expert method is: First there is fluctuation one to the 
liquor amnii, and this declares its cystic nature. 
Tait's sign of pregnancy. If the hand is lain gently on the parietes a 
rhythmical contraction of the uterus by which 
at one time it is as hard as a cricket ball, and at another, soft as 
a cushion, will become perfectly evident. This alternate contrac- 
tion and relaxation of the pregnant uterus "is a method of diagno- 
sis which, when once made apparent, can never be mistaken for 
anything else." 



LECTUKE XVIII. 

BlLIOUS COLIC DURING PREGNANCY. 

Bilious colic in pregnancy; Albuminuria in ditto; the Nausea and Vomiting of do.; Vari- 
cose veins. 

We will devote the first part of this hour to the study of a case 
of bilious colic in a woman who is pregnant. 

Case. — Mrs. D , aged 30, a healthy looking woman of bil- 
ious temperament, with black hair and eyes, is six months ad- 
vanced in her third pregnancy. She complains of repeated attacks 
of bilious colic, which are accompanied by the usual symptoms of 
that disorder. Sometimes the paroxysm is very acute, and of brief 
duration, coming on abruptly and going off in the same manner. 
Again, the pain is more dull, steady, and persistent, lasting per- 
haps for twelve hours or more. These paroxysms are not refera- 
ble to errors in diet, or to excess of exposure, labor or worry, as 
in ordinary bilious colic, but recur without any obvious cause, 
sometimes waking her out of a sound sleep. She had them 
throughout both of her former pregnancies, but never at any 
other time. She carried both of her children to term. Unless 
they have continued for six hours or more, the attacks of pain are 
not followed by jaundice. Her father and two of her uncles were 
subject to severe fits of bilious colic. 

This case illustrates the peculiar relation existing between the 

uterus and the liver, — a subject of study which is really more 

important than you may have supposed. For, 

The vascular relation be- . • -i-i i i 

tween the uterus and the not only are these viscera organically related 
through the sympathetic and spinal nervous 
systems, but their vascular connections also are peculiar and sig- 
nificant. 

The portal vein receives blood from each and all of the chylo- 
poietic organs. Without this supply of blood from the stomach, 
the intestines, the spleen, the pancreas, and the mesentery, the 
curious and complex function of the liver could not be properly 
performed. But this is not all. The vaginal, hemorrhoidal, uterine, 
and ovarian plexuses of veins also communicate, by anastomoses, 

293 



294 THE DISEASES OF WOMEN. 

with the portal system, as well as with the inferior vena cava. A 
portion of the return current of blood is therefore conveyed 
directly from the pelvic organs to the liver, en route for the gen- 
eral circulation. 

Whether this vascular arrangement really implies such a com- 
pensatory relation between the hepatic and uterine functions as 
was insisted upon by Stahl and others, it is foreign to our present 
purpose to inquire. Its very existence suggests the possibility of 
diseased conditions which shall depend upon some derangement of 
the circulation in these inter-communicating vessels. 

One of the most marked of the anatomical changes consequent 
upon conception is found in the uterine veins. They become en- 
larged into canals and sinuses, with an increase 
rrv?duteru C s han§es in the °^ ca P a city which is in ratio with the nutri- 
tive demands of the contained embryo or foetus. 
Being destitute of valves, the only safeguard against a regurgita- 
tion and stasis of blood in them is their tortuosity, and perhaps, 
also, as Kollicker has shown, the temporary supply of muscular 
fibres to their middle coats. 

A woman becomes pregnant. Prior to this she may have been 

very healthy. She may or may not be of a bilious temperament. 

But within the month, and sometimes almost 

Bilious symptoms in early immediately, the hepatic and intestinal func- 

pregnancy. J 1 *■ 

tions are deranged. She has nausea and vom- 
iting, which, as in bilious affections uncomplicated with gesta- 
tion, are worse in the morning. The tongue is furred, the breath 
foul. She has no appetite for breakfast, there is disgust of water, 
almost invariably constipation, with bilious headache, highly-col- 
ored urine, and hypochondriasis. The matter vomited consists 
chiefly of mucus, but the paroxysm does not terminate until more 
or less of bile, it may be only a few drops, is ejected. 

These symptoms are commonly known as " bilious." That they 
are contingent upon pregnancy is a matter of every-day observa- 
tion. But that the extraordinary development 
ium he uterus a diverticu " of the vascular system of the uterus consequent 
upon conception is their indirect cause, is not so 
generally recognized. This functional derangement of the liver 
may arise from sluggishness of the venous circulation in the pel- 
The uterus becomes a diverticulum which receives 



THE DISEASES OF PREGNANCY. 295 

and retains an unusual quantity of venous blood. Its weight is 
increased, it suffers a temporary prolapse, pressure therefrom in- 
creases the obstruction in the local circulation, and the parts which 
are even remotely related through a common vascular apparatus 
are almost necessarily implicated. 

A similar result may happen in the case of uterine deviations 
of whatever kind, but more especially in prolapsus, procidentia, 

and retroversion, in uterine scirrhus, fibroids, 
utSne affect g io r rf s ement ' m or P or ypi ' i n chronic metritis, dysmenorrhcea, 

amenorrhcea, and uterine ulceration. As haem- 
orrhoids and dysentery, and similar diseases in the ano-pelvic 
region, are very liable to be complicated with some hepatic dis- 
turbance, so it is with these different lesions of the womb. And 
since a proper supply of bile is indispensable to intestinal diges- 
tion, we see at a glance what a blow is aimed at nutrition when 
the function of the liver is thus deranged. In this list of diseases 
there is not one which is not usually accompanied by more or less 
of indigestion and inanition. 

Now the chief office of the liver, as an excretory organ, is to 
eliminate the cholesterin, which results from the destructive 

changes going on in the nervous substance or 

Cholestrsemia contingent . . . 

upon pregnancy and uter- neurme. 1 his post-organic product would be 

ine disease. m -,.-,.. 

poisonous if retained in the blood, and it is 
therefore expelled by way of the hepatic and intestinal outlet, just 
as urea escapes through the urinary apparatus. And, as we ob- 
serve that the muscular tissue, of which it was so recently an 
integral part, is peculiarly susceptible to the toxical effects of an 
excess of urea in the blood, so the nerve-centers, the brain espe- 
cially, are extremely sensitive to the action of cholesterin. Hence 
the hypochondriasis of pregnancy, and of most chronic uterine 
affections, which owes its origin to torpidity of the liver, and to 
the imperfect performance of its excretory function. And hence, 
also, the possibility of such suffering as that of which our patient 
complains. For biliary calculi consist chiefly of cholesterin, and 
their existence in a given case is proof positive of hepatic derange- 
ment. 

Bilious colic is therefore a contingent of pregnancy. There are 
those who, like Mrs. D., never have it except when they are preg- 
nant. Some, however, are liable to it whenever they menstruate ; 



296 THE DISEASES OF WOMEN. 

others in consequence of excessive sexual intercourse or excite- 
ment , and I have known it to be caused by wearing an ill- 
adjusted or a misplaced pessary. 

Treatment. — We have proof that a knowledge of the organic 
relations between the uterus and the liver is practically import- 
ant, not only in the clinical history of similar 

Common influence of . . 

remedies on the uterus cases, but also in the known common influence 
of different remedies over these organs. Take, 
for example, nux vomica, aloes, podophyllin, and chamomilla, as 
they are most frequently prescribed in uterine and intra-pelvic 
affections generally. The symptoms which guide to the selection 
of any of these remedies usually pertain to the liver, or to some 
portion of the intestinal tract, rather than to the uterus and its 
appendages. 

There are, it is true, many exceptions to this rule, but the clini- 
cal fact is suggestive. In uterine lesions especially, the dial-plate 
upon which their characteristic symptoms may 

The symptoms of uterine i -i • i , i -i -i i r> 

disorder may be remotely be read, and which must be consulted betore 

located. • 

Ave can treat them understandmgly and success- 
fully, is often located where you would least suspect, it, — some- 
times in the liver, or in some portion of the gastro-intestinal tract ; 
again in the heart, the brain, or the general nervous system, and 
even in the eye. Hence a great variety of remedies may be 
requisite in uterine therapeutics, and the necessity of careful 
study in their employment must be apparent to you all. 

Before the termination of pregnancy, and while the cause is still 
in operation, we should be chary of promising a radical cure in a 

case of this kind. The disease being self-lim- 
This form of bilious de- {ted, its symptoms may not wholly disappear 

rangement self-limited. J x. J J x i 

until term. In exceptional cases, however, 
there may be but one or two attacks of the colic. During the 
paroxysm the indication is to afford prompt relief from the suffer- 
ing. Among the remedies most frequently 

Remedies during the fit. . 

employed lor this purpose are nux vomica, 

podophyllin, chamomilla, atropine, and chelidonium. With some 

practitioners the dioscorea is in excellent repute. Inhalations of 

ether or of chloroform may be justifiable in ex- 
Local palliatives. . . 

treme cases. In hysterical subjects, with threat- 
ening spasms, ignatia, belladonna, or hyoscyamus may be called 



THE DISEASES OF PREGNANCY. 297 

for. Dry heat, in the form of hot plates wrapped in flannel, or 
bottles of hot water, or clothes wrung out in hot water and applied 
over the seat of the pain, are sometimes most grateful and bene- 
ficial. The warm bath is contra-indicated in case of bilious colic 
■occuring in a pregnant woman. 

China is perhaps the best prophylactic against bilious colic. It 
seems to hold some specific relation to the formation and excre- 
tion of cholesterin. We do not know precisely 
what that relation is. Whether it stops the 
destructive metamorphosis of ne urine, and thus limits the produc- 
tion of cholesterin, or helps the liver to eliminate it more readily, 
is an unsettled question. At all events, we may avail ourselves 
of the clinical fact that it serves to palliate and to prevent painful 
attacks of this disorder. When prescribed with this intent, it 
should be given once or twice daily. In a case like the one before 
us, china will not interfere with gestation. Mrs. D. will take this 
remedy morning and evening. 

Her diet should consist of albuminous substances, and fruits. 

Fats, and all kinds of pastry, would be poison- 
Diet; mental and Q ^ T j ^ mQ { t f £ an( j ^ jj 

physical exercise. ^ 

She should have daily exercise in the open air, 
and be especially careful to avoid all sources of mental anxiety. 

ALBUMINURIA IN PREGNANCY. 

Case. — L. W. C , 19 years of age, primipara, weighing 180 

pounds, was admitted to the hospital at the eighth month of preg- 
nancy. She is of full habit and is troubled with headache and 
" flushes." On being tested by heat and nitric acid, the urine was 
found to be highly albuminous. She had previously taken apocy- 
num can., and arsenicum alb., without any benefit. The feet and 
legs were enormously swollen, so that she could not walk or 
stand with any degree of comfort. She felt wretched, nervous 
and apprehensive. 

She took mercurius corrosivus in the 3d decimal trituration 
once in three hours. The proportion of albumen in the urine 
lessened almost immediately, and continued to decrease, so that 
there was a mere trace of it the day before her delivery. Although 
we had anticipated convulsions, her labor came on naturally, and 
was completed without a single untoward symptom. Her child is 
now three weeks old, and all the dropsical and urinary symptoms 
have entirely disappeared. 

I do not know where vou will find a case of disease which is 



29S THE DISEASES OF WOMEN. 

the cause of greater mental strain and anxiety than such a one as 
this has been. To feel and realize that in all probability a woman 
who is approaching term will have puerperal eclampsia, and that 
her lite and that of her offspring depend almost entirely upon your 
skill, is a great load to carry. It should interest you to know how 
such a calamity may sometimes be averted. 

A pregnant woman at the eighth month may have dropsical 

symptoms which do not forbode any ill of this kind. But if she 

has decided albuminuria, with dropsv of the 

Signs of convulsibility. . , 1 . , . . J , . A . 

race and extremities, with or without amauro- 
sis, the probabilities are that, unless this is relieved, her delivery 
will be accompanied by convulsions. How to remedy this single 
symptom may therefore be a very important question for you to 
decide. 

Experience has led me to place great confidence in the mercu- 
rius corrosivus. I have prescribed it very frequently to fulfil this 

precise indication, audit has seldom disappointed 

Mercurius corrosivus. . 

me. lhe clerk mis furnished me notes of an- 
other case which occurred in the hospital some weeks ago, in which 
the effect of this remedy was equally satisfactory. 

Case. — Nancy J., aged 29, primipara, was eight and a half 
months advanced in her second pregnancy when she was admitted 
to the hospital. She reported that she had had dropsical symp- 
toms for two weeks already. The legs and ankles were very 
much swollen, the ankles being so puffy that the infiltrated 
integument hung over her slippers. The face and eyelids were 
cedematous, and she complained of much headache. On examina- 
tion the urine was found to be albuminous. She also had a 
partial amaurosis, which began and subsided with the dropsical 
symptoms. 

She took the mercurius corrosivus 3, a dose every three hours. 
The albumen disappeared from the urine, so that the day before 
her delivery no trace of it could be discovered. She passed through 
parturition and lying-in without any convulsions. 

In presenting these cases the idea which I design to convey 

is not that this, or any other remedy, is an absolute specific for 

ante-partum convulsibility. There is no real 

There is no Infallible . x , ' _ v . _> ' .„ . 

prophylactic for con- prophylactic of puerperal eclampsia. Jout if in 

one case in ten, you can recognize the incipient 

symptoms of this dreadful disease and avert it, you should know 

how to do it. Therefore, I recommend you not to fail to apply 



THE DISEASES OF PREGNANCY. 29^ 

the tests for albuminuria whenever any of its symptoms are present 
in the latter mouths of pregnancy, and not to forget that the 
mercurius corrosivus is in many cases an invaluable remedy for 
it. When Nature " flags the train" we should always take the 
hint.* 

ABDOMINAL CRAMPS AND PAINS IN PREGNANCY. 

Case. — Mrs. S is six and a half months advanced in her 

second pregnancy. For three weeks past she has complained of 
occasional pains and cramps in the abdomen. These sufferings 
are increased by exercise, slight pressure, emotional causes, and 
especially by the too vigorous movements of the foetus in utero. 
Upon examination I found the abdominal parietes somewhat 
attenuated, and the uterus in the position of the right lateral obli- 
quity. Otherwise I discovered nothing abnormal. 

Unless the uterus is very decidedly displaced, abdominal and 

sacral pains, cramps in the limbs, and like symptoms, are not very 

apt to worry the pregnant woman prior to 

cramps etc., after qmc keniiiff. After the fourth month, however, 

the fourth month. l ft » ' 

and in exceptional cases as early as the third, 
they may be the cause of much suffering. They depend on the 
changes which the uterine and abdominal structures necessarily 
undergo in consequence of the development of the foetus. As you 
would naturally suppose, these symptoms are most frequently 
met in primipane — those who have never borne children before. 
Occasionally we find a patient who always experiences them dur- 
ing pregnancy. 

As the uterus enlarges there is a gradual distention of the 
abdominal walls. Avery natural consequence of this distention is 
the production of muscular and neuralgic pains. These pains, 
which are sometimes general, again local — as in certain forms of 
hysteria — sometimes shooting and cramp-like, and again more 
constant, are very likely to be referred to the points of attach- 
ment of the various muscles which comprise the parietes of the 
abdomen. They may be felt in either the right or the left hypo- 
chondrium, in the iliac or umbilical region, and finally may settle 
into the permanent lumbar distress which in many cases precedes 
abortion. Not unfrequently, on account of its tension and 

* In all suspected cases it is a good rule to examine the urine occasionally, more espe- 
cially after the sixth month. This is a simple, and withal an important matter, for the 
renal complications of pregnancy and of parturition are mainly avoidable. 



300 THE DISEASES OF WOMEN. 

extreme tenderness, when the belly has become hard and full, the 
skin is the seat of the difficulty. In such a case there is a neu- 
ralgic affection of the cutaneous nerves, which is frequently mis- 
taken for inflammation of the womb and its appendages. 

In most cases like the one before you, and whatever its seat 
and character, the suffering is increased by motion. Any exercise 
which renders it necessary for the patient to 
saving 1 ! increases the breathe more deeply and frequently than 
natural ; coughing or straining at stool ; riding 
or walking , turning in bed, or getting into an upright from a 
horizontal position ; the rolling of flatus in the bowels, or the move- 
ments of the foetus in utero ; may produce or aggravate it. It is 
usually worse when upon the feet than when sitting, and when 
sitting than when lying. There are, however, many exceptions to 
this rule. Excepting towards the end of pregnancy, say after the 
seventh month, it is generally worse in the day and better at night. 
It may be increased by mental emotions, as fright or anxiety ; and 
is more annoying and obstinate in those who are of sedentary habits 
than with the active and industrious. Lean women are more liable 
to it than the more robust. In rheumatic and neuralgic subjects it 
may depend upon vicissitudes of wind and weather for an excit- 
ing cause. Puny, nervous, and delicate children are more active 
and restless in utero, and therefore occasion more suffering of this 
kind, than those that are strong and vigorous. 

Diagnosis. — With respect to the prognosis and treatment, it is 
very important to be able to differentiate between the several 
varieties of abdominal pains to which pregnant women are subject. 
Among the lesions to which they are especially liable, we should 
separate the peritoneal from the neuralgic, the muscular from the 
uterine, and the ovarian from the intestinal. 

There is a spurious or false peritonitis, which rarely occurs 

except at the menstrual period, or at the time in the month which 

corresponds to it during gestation. It usually 

Spurious peritonitis. 1 1n . „ 

commences with a chill and local pain 01 an 
acute, lancinating character, in the region of one or both ovaries. 
The corresponding limb is flexed, and cannot be straightened 
without great increase of suffering. The affected part is exceed- 
ingly tender to the touch, and pressure, slight or severe, is insup- 
portable. This pain becomes gradually more diffuse. These 



THE DISEASES OF PREGNANCY. 301 

symptoms are accompanied by more or less fever and constitu- 
tional disturbance. 

In the cutaneous neuralgia, although the diagnosis is not diffi- 
cult, the most unpardonable blunders are frequently made. Tar- 

nier's remarks upon the subject are exceedingly 
neurafiia Sisfromcutaneous appropriate, and I quote them :* " Having for 

some time made a special study of these abdom- 
inal, inguinal, and lumbar pains, we are convinced that very 
often they are due to neuralgia of the cutaneous nerves from the 
collateral branches of the lumbar plexus. To be assured that 
such is the case, it is only necessary to test carefully the sensi- 
bility of the skin in these regions, either by rubbing it rudely 
with the end of a pencil, or by raising it in the form of a fold 
which is to be gradually pinched between the fingers. Pressure 
ought also to be made all along the crest of the ilium, in the 
direction of the genito-crural nerve. Should we be satisfied with 
merely questioning the patient, or depressing the walls of the 
abdomen by the hand, we would incur the risk of obtaining very 
little information, or of suspecting the existence of deep-seated 
visceral pain when the skin only is affected. This mistake, which 
we see committed every day, would be avoided by taking the 
trouble to make the above-mentioned examination, and we can- 
not recommend it too highly. The principal parts affected by this 
neuralgia are the lumbar, iliac, hypogastric, and inguinal points, 
though the pain may appear in some other portion, of greater or 
less extent, of the skin of the abdomen. Sometimes confined to 
a circumscribed point, it occasionally invades an entire half of 
the abdominal walls. It very rarely affects both sides at the same 
time with equal intensity." 

If the abdominal muscles are the seat of the suffering, the pains 
are cramp-like, and accompanied by knotting of the fibres, which 

is worse upon pressure or motion. The suffer- 

Characteristic symptoms. . • 

mg between the severest paroxysms is referred 
to the points of origin and insertion of separate muscles. This 
form is most frequent in rheumatic subjects, in whom there may 
be a sudden metastasis to either of the larger articulations. It 
sometimes arises from traumatic injuries, as, for example, a blow 
or fall upon the abdomen. 

* Cazeau's Midwifery, Revised and Annotated by S. Tarnier. Phila. : 1868. p. 521. 



302 THE DISEASES OF WOMEN. 

Metritis is a rare concomitant of gestation, but we not unfre- 
quently encounter a species of uterine colic that is apt to be mis- 
taken for one of the former affections. Hyster- 

Uterine colic. . . . 

ical women, who are highly emotional, and, I 
may add, exceedingly impulsive and imprudent also, are liable 
through some indiscretion, to attacks of this kind, and more 
especially about the period of quickening. So, also, are those 
who have been martyrs to dysmenorrhcea. The pain is referred 
to the uterine region and remains there. It may be intermit- 
tent, but it is not erratic like the muscular variety. It is prone 
to assume some of the characters of labor pains, and if long con- 
tinued or extreme in degree, may really precipitate a miscarriage. 
If we except their peritoneal envelope, the ovaries are singu- 
larly exempt from disease during pregnancy. From the date of 
conception their function is physiologically sus- 
diSasr ption from ovarian P en( ied and the condition which threatens their 
healthy action while menstruation continues is 
withdrawn. From various causes, however, their investing mem- 
brane may become inflamed, in which case the symptoms need 
not be confounded in your minds. The pain which -is referred to 
the ovarian region, is sharp, and sometimes intense, or pressing, 
throbbing, burning, and paroxysmal. It may radiate over the 
abdomen, or extend into the back, or down the limb of the affect- 
ed side. This limb is generally flexed, or if the patient tries to 
walk, she is lame with it. In exceptional cases pregnant women 
are, however, liable to a form of ovarian neuralgia. 

The gastro-intestinal disorders incident to pregnancy are more 
annoying and frequent before the fourth and after the seventh 
month than between these two periods. When- 
de? s a fncidSt e to n r a i nine*" ever tne y occur, however, they are accompa- 
nied by such marked digestive derangement that 
you will have little trouble in their differential diagnosis. 

Prognosis. — I recommend you in no instance to regard a case 
of this kind as trivial. For there is not one of them which is alto- 
gether exempt from the liability to abortion and its fearful conse- 
quences. Throughout its whole course, the state of pregnancy is 
beset with contingencies which it is your duty to avert. And not 
the least serious among them are such as may develop from symp- 
toms like those of which our patient complains 






THE DISEASES OF PREGNANCY. 303 

Treatment. — This is one of those cases which we often encount- 
er in private practice, and which are distinguished by this pecul- 
iarity — they are better managed by simple domestic expedients than 
by the most scientific prescriptions. Yet, as I have said, we must 
discriminate. For example : 

If the pains are muscular, the part may be bathed quite fre- 
quently with hamamelis. Perhaps as large a proportion as one- 
half of all the pregnant women who complain of these symptoms 
may be relieved by this means alone. It is equally appropriate in 
ovarian irritation and inflammation. In some cases the rhus toxi- 
codendron answers a good purpose. I generally direct a table- 
spoonful of the strong tincture to be put into a teacupful of tepid 
or cool water, and then applied through one or more layers of 
flannel. 

If the suffering has been caused by mechanical means, or is the 
result of injury, the tincture of arnica may be applied in the 
same manner. 

If it is caused by undue pressure against the attenuated walls 
of the abdomen, you may counteract this effect by enveloping the 
abdomen in several layers of an elastic bandage of rubber-cloth 
in such a manner as to support its parietes. A bandage of linen 
would be too unyielding, and might indirectly induce abortion. 

Toward the latter end of pregnancy the feeling of extreme dis- 
tention and discomfort in the abdomen, will often yield to the old 
and simple expedient of anointing it with sweet oil. I have seen 
the most threatening symptoms of premature labor relieved in 
this manner. If the pains are cramp-like, the camphorated oil is 
an excellent application. 

If the suffering is neuralgic, you will charm it away by direct- 
ing that the affected part be covered with simple, dry, uncarded 
cotton, or cotton batting. In some cases, several layers of flannel 
will answer equally well. Belladonna, or atropine, internally, 
may hasten the cure. 

In the ovarian neuralgia which sometimes complicates the symp- 
toms, and greatly increases the suffering in these cases, I know of 
no remedy to compare with the valerianate of zinc. I shall have 
more to say in future of this contingent of pregnancy. 

It is very important always to regulate the exercise of the 
patient, and as far as possible to prevent too much of mental fric- 



304 THE DISEASES OF WOMEN. 

tion and anxiety on her part; for, although anatomists have failed 
to demonstrate a nervous connection between the mother and the 
foetus in utero, her mental emotions do influence it greatly. It is 
a bad habit for those who are pregnant to take care of, and to lift 
and carry around, other children in the family. Although tight- 
lacing is popularly believed to contribute to an easy and safe labor, 
it is often prejudicial to the comfort and welfare of the pregnant 
woman, by inducing abdominal pains and cramps which may result 
in abortion. 

Internally, a variety of remedies may be indicated. Where, as 
in this case, the suffering is aggravated by motion, however slight, 
bryonia will sometimes afford almost instant relief. Nux vomica, 
Pulsatilla, belladonna, rhus tox., ignatia and chamomilla, are also 
useful under appropriate indications. The patient will take bry- 
onia 3d, three times daily, and report at the end of a fortnight, 
or of three weeks at the farthest. 

THE NAUSEA AND VOMITING OF PREGNANCY. 

The sickness and vomiting of pregnancy are sometimes very 

difficult to explain, and still more difficult to cure. They usually 

expire by limitation at or before the fourth 

May occur at an early, mont } 1 ^ ut mav T) e o;in or end at any time before 

or late period. J ° ^ 

delivery. The difficulty that has been experi- 
enced in curing it, is shown in the long list of remedies that have 
been recommended for it. The list of specifics for morning sick- 
ness includes about one half the remedies in the materia medica. 
In rare cases this is a fatal affection. Sometimes it terminates 
In abortion ; in others the death of the foetus puts a stop to it, 

even although its delivery may be delayed for 

Is sometimes fatal. , , ml , . , . , 

some days or weeks. I he most persistent and 

uncontrolable vomiting of food may threaten to destroy life 

through inanition, and yet the patient may 

If uncomplicated is continue in g 00C l fl es h. For, SO long as this 
not dangerous. © . 

disorder is not linked with a serious organic 
lesion of some portion of the digestive apparatus, the prognosis is 
favorable. 

You may remember that the worst cases are those which are 
associated with chronic and intractable disease of the liver. I 



THE DISEASES OF PREGNANCY — CONTINUED. 305 

never like to see a patient who is suffering from excessive gastric 

disturbance during pregnancy, begin to show 

significance of a coin- . of j aimcUce especially if she has never had 

cident jaundice. n J » i J 

it before, or if there are coincident symptoms of 
acute yellow atrophy of the liver, or of uraemia. 

There are some cases of morning sickness which manifestly 
depend, as Rene Brian and Grraily Hewitt have shown, upon a 

flexion of the uterus. In these cases the gastric 

May depend upon disturbance is neither very severe nor long con- 
uterine deviations. 7 ° 

tinued, and yet they do sometimes result in 

abortion. Their diagnostic sign, apart from a local examination, 

is that the sickness is limited to the time of rising from the bed, a 

condition which is explained by the effect of gravity in bending 

the uterus upon itself. There are cases, however, in which the 

flexure of the gravid uterus does not excite emesis. 

In accounting for this vexatious infirmity the displacement 

theory is the oldest. It has also been ascribed to ulceration, 

inflammation, and stricture of the cervix uteri, 

Various causes assigned. - . . ' . . , «, 

to the stre tennis: ol the uterine muscular fibres 

CD 

during their development, to chlorosis, to albuminuria uraemia, 
and to sympathetic irritation of the pneumogastric. After the 
seventh month it may be due to mechanical pressure of the gravid 
uterus upon the stomach or the liver. 

The matters vomited will vary with circumstances. If the 

attack recurs when the stomach is empty, the egesta will consist 

of a viscid or slimy fluid ; if there is a great deal 

The matters vomited. _ . . 

ot retching, it may be bilious, or even bloody: 
if the patient has eaten heartily, the food and drinks may be 
rejected. 

Treatment. — There is no real specific for this disorder ; nor can 
we find in the character of the retching, the nausea, the matters 

rejected, the occurrence and frequency of the 

Lack of a specific for. ° ,. ' f . 

paroxysm, the degree or quality of suffering, or 
the disgust of food, such indications lor our remedies as will 
always help us to prescribe both accurately and successfully. 
Even where certain remedies have been extolled, there is often a 

doubt concerning their efficacy, because some- 

Questionable results. i i i • i • 

thing else has been given, or done, simultane- 
ously for the relief of the suffering. Here is a case in point, which 

20 



306 THE DISEASES OF WOMEN. 

I will quote from the JSf. E. Medical Gazette, vol. 4, page 153, to 
which it was contributed by my friend Dr. W H. Holcombe, of 
New Orleans: 

Case. — -I was called, two weeks ago, to a very distressing case 
of this kind ; and the treatment, whether strictly homoeopathic or 
not, was so promptly efficacious that it is worth recording. 

The lady was pregnant last year, and suffered horribly for seven 
weeks under allopathic treatment. She was only relieved by an 
abortion. This time she had suffered for three weeks before I was 
called in. She vomited about every half hour in the twenty-four, 
and no nourishment had been retained for more than five minutes, 
for a week or ten days. She was much emaciated, and greatlv 
prostrated from want of nourishment and sleep. She was cold, 
trembling, and wretchedly nervous and despairing. 

I ordered nux 30, and platina 30, alternately, every hour, and in- 
jections of beef- tea and brandy every six hours. 

I found her a little better the next day, but not enough so to 
satisfy me that I was on the right remedies. So I examined my 
case more thoroughly. 

I found two peculiar symptoms, which I regarded as key-notes. 
She was always greatly worse on waking from her little naps of 
sleep. Indeed, she declared she had rather not sleep at all than to 
awake with such dreadful sensations. Secondly, she referred her 
nausea entirely to a strange trembling, like a mass of jelly, which 
reached from the umbilicus to the ribs, and over the gastric and 
hepatic areas. I felt this tremulous motion with my hand 
for a long time. It was a quick sub-cutaneous quivering, almost 
without intermission. These symptoms belong especially to 
lachesis. 

I ordered lachesis 2000, every hour. When I went next day, I 
found my patient in ecstacies. She had slept half the night, had 
vomited only a few times, and the trembling sensations had almost 
disappeared. What a brilliant laurel this would be for lachesis, 
if lachesis alone had been used ! But, alas ! my spirit of empiri- 
cism had dictated an adjuvant in the shape of an injection at night, 
of twenty grains of the bromide of potassium, and I could not tell 
positively which effected the cure. 

Afraid to drop either, and consulting the good of my patient 
in preference to my own pure homoeopathicity, I continued the 
prescription— lachesis 2000, — during the day, and a nightly injec- 
tion of twenty grains of bromide of potassium. In a few days 
my patient was up and at the table, enjoying the pleasures of life, 
to the astonishment of her friends and to the glory of Homoeo- 
pathy. 

I believe the lachesis was the curative agent, — firstly, because I 



THE DISEASES OF PREGNANCY CONTINUED. 307 

Relieve lachesis in the higher and highest dilutions to be a remedy 
of astonishing value; secondly, because it covered my case 
homceopathically ; thirdly, because, although the bromide of po- 
tassium is a good remedy for great nervous excitation, I have tried 
it several times before in the vomiting of pregnancy, and never 
with any decided result. 

Nux 30, and lachesis 30, have done more for me than any other 
remedies in the vomiting of pregnancy, ipecac 200, and platina 30, 
stand next in my confidence. Plumbum, opium, and tarantula, all 
high, will repay careful study in difficult cases. 

Nourishment by enemas of beef-tea, cream, milk-punch, etc., 
should be early and steadily employed. 

The following indications for some of our well-known remedies 
have a clinical confirmation : 

For the vomiting of a viscid mucus, especially on rising, nux 
vomica and cocculus. For constant, or occa- 

Speeial indications for . , ... .., , J ., , J# „ 

remedies. sional vomiting, without regard to the position of 

the body, and for vomiting of whatever is swal- 
lowed, the egesta being mixed with bile or mucus, ipecacuanha. 

If the mucus is milky and the patient has had, or is having, 
leucorrhcea, and yellow spots on the skin, sepia. 

For the vomiting of fluids as soon as taken, with thirst, great 

uneasiness and restlessness, bitterness in the mouth after eating 

or drinking, with pallor of the countenance, and thirst for cold 

brinks, arsenicum. 

t 

For the vomiting of a greenish, frothy mucus, which is some- 
limes relieved, temporarily, by drinking cold water, especially if 
there is a copious flow of saliva, cuprum metallicum. 

For the vomiting of bile with the food, a rancid heart-burn, 
and ptyalism, especially at night, mercurius. 

Other remedies, the special indications for which you will look 

to the materia medica, are, apis mel., berberis, 

a list of possible rem- bismuth, conium, cimicifuga, calcarea carb., 

edies. 

chamomilla, ferrum, ignatia, kali carb., kreoso- 
tum, natrum mur., petroleum, tartar emetic, veratrum alb., and 
zincum, podophyllum, and iris vers. 

The number and variety of these remedies implies that the so- 
called morning sickness of pregnancy is a self-limited disorder, 
because when a disease inclines to get well of itself it may easily 
happen that whatever has been prescribed will sometime or other 
get the credit of having cured it. 



Stretching the cervix. 



308 THE DISEASES OF WOMEN. 

There are a few medicines and expedients that have been used 
empirically with advantage, amonsf which are- 

an^ir"^ the oxalate of cerium > apomorphia, pepsin, the 
eats. sulphate of soda, the arsenite of copper, gossy- 

pium, the bromides of soda and potassa, good old wine, cham- 
pagne, coffee, luke-warm gruel, and very w T eak green tea. 

If the uterus is displaced its careful reposition will be necessary. 
I shall speak of this directly. Exceptionally, if 
the os uteri is badly ulcerated, it may be neces- 
sary to treat it locally with a bland, unirritating application such 
as calendula, hamamelis, or hydrastis and glycerine. I have fre- 
quently arrested the gastric disturbance for days together by the 
topical use of the oleaginous collodion. 

The newest expedient, with which a distinguished gynaecologist 
has proposed to do away with morning sickness 
altogether, consists in the dilatation of the 
cervical canal. The mode of performing this little operation is 
to carry the index finger gently through the external os, with a 
rotating movement, until one-half of the first phalanx has been 
introduced. In the case of multiparas this is easily done; but 
with primiparae it will sometimes be necessary to dilate the os by^ 
other means before the finger can be passed. The objection to it 
is that there is considerable risk of inducing abortion. This plan 
of treatment w T as discovered by Copman, in 1875, who, for the- 
purpose of causing an abortion for the relief of vomiting in a 
case ot pregnancy, dilated the cervix with his finger, and cured 
the vomiting without any other result. 

The fact that, in very rare cases, when the life of the woman is 

seriously threatened, the induction cf abortion or of premature 

labor is sometimes necessary for the relief of 

The expediency of this and kindred disorders, makes it incumbent 

abortion. 

upon me to say a word or two upon this subject. 
There are but two indications which can render this extreme resort 
imperative, viz., (1) where it is morally certain that if the gastric 
disturbance continues the woman may die of starvation; and, (2) 
where there is such a coincident disease, more especially of the 
liver and kidneys, as makes it equally certain that she will die if 
the remote cause of the trouble is not removed. 

Concerning the first of these indications, we are learning in 






THE DISEASES OF PREGNANCY. 309 

various ways that the human organism can withstand and survive 

an almost total lack of food for a considerable 
JL danSerfr ° m ln " Period. Perhaps there is no condition in which 

a woman can be placed, in which so small an 
amount of food will suffice, as during the first few weeks of preg- 
nancy, when the nutritive needs of the embryo amount to little or 
nothing, and her appetite and taste are so thoroughly upset. Under 
these circumstances you must not be surprised nor discouraged if, 
for what may seem an incredible time, all food whatever shall be 
either refused or rejected. Such patients will not be likely to die 
of starvation, and therefore, you had better wait and work for a 
favorable change, rather than resort to an expedient which in- 
volves a moral wrong. 

A mere functional disorder of the liver, the kidneys, or any of 
the pelvic or abdominal viscera Avould not warrant the recourse to 

such a terrible expedient. In case of pressure, 
p.la;r.e"oo r r COm ' : «Pon the liver by the gravid uterus after the 

seventh month, if the disease in that organ is of 
so serious and so threatening a nature as to imperil the life of the 
patient, and where the best treatment has failed to bring relief, it 

mav become a question whether the induction 

From hepatic disease. „ " . . 

oi premature labor is not both right and proper. 
For, under these circumstances the expedient concerns the saving 
of the child's life, as well as the cure of the mother. 

Where, in the later months of gestation the urinary complica- 
tion depends upon the same kind of pressure on the renal 
vessels and the ureters, vou may need to 

From uraemia, etc. . 

balance this same question most carefully and 
conscientiously. The mere giving of remedies, or even the 
hypodermic injection of apocynum to stimulate a flow of 
urine, so strongly Becommencled by my friend Dr. Fahnestock 
at our Clinical Society, will not always answer.* But, before 
resorting to such an expedient as the induction of prema- 
ture delivery, you must be certain that these conditions do really 
exist, and that the life of your patient is endangered by this par- 
ticular cause. 

Observe that the question is not whether you must hasten the 
delivery in all cases of ursemia with albuminuria occurring in 

*Vide The Clinique for October, 1880. 



310 THE DISEASES OF WOMEN. 

pregnancy; but whether, when the means that are usually suffici- 
ent have all failed, we should try this as a last resort. This is the- 
question that you must settle for yourselves in each individual 
case with the aid of the best counsel that you can procure. 

In the same journal for November, 1880, you will find a report 
upon the treatment of nausea and vomiting in pregnancy that was 
read before our Society by my colleague Prof. Hawkes. This 
paper gives the details of several very interesting cases that were 
cured by mercurius, cocculus, arsenicum and lycopodium. The 
discussion that followed its presentation drew forth some inter- 
esting facts and points of a clinical kind, more especially with 
reference to the self-limited nature of this distressing affection, 
and the possibility of curing it, in exceptional cases, by the most 
irregular, and outlandish prescriptions. As a specimen of the 
latter Dr. Small cited the case of a woman who had suffered sa 
severely from this disorder that she was compelled to take to her 
bed and to stay there during the whole of gestation. She had 
tried, during her successive pregnancies, both schools of practice, 
and had been under the care of Dr. Constantine Hering, but 
without relief. Finally, an old woman cured her promptly with 
a tumbler of hard cider, which contained a teaspoonful of salt and 
an old rusty nail. 

VARICOSE VEINS. 

In remarking upon a case of varicose veins of the legs in a preg- 
nant woman, Prof. L. expressed great confidence in the value of 
hamamelis. He gives it internally in the third decimal dilution, 
and uses it locally in the form of one part of the mother tincture, 
or ot Pond's Extract, to three parts of tepid water, which is to be 
applied by cloths or compresses that are wet with the lotion. 
Sometimes relief is afforded by bandaging the limbs from the feet 
to the hips with a surgeon's roller, but the same indications are 
filled, and more perfectly too, by the modern elastic stocking. It 
is a self-limited affection, usually ending with pregnancy; but, at 
term, it should always be regarded as a predisponent of puerperal 
phlebitis. 



LECTUEE XIX. 



MORNING SICKNESS OF PREGNANCY, AND RETROVERSION. 

Morning' sickness of pregnancy and retroversion; Nausea and vomiting of pregnancy; 
Chorea during pregnancy. 

The first case this morning is one that illustrates the distressing 
affection known as " morning sickness," for which the doctors 
have thus far failed to find a specific. 

Case. — Mrs. G., aged 35, has reached the third month of her 
fifth pregnancy. Her first two children, a son and a daughter, 
were carried to term and are now living. She has aborted twice 
at about three and a half months, in consequence, as her physician 
told her of retroversion of the womb. The chief peculiarity ot 
the case is that the nausea and vomiting which are incident to the 
early months of gestation are experienced by her at night only. 
It commences each evening at ten, and continues, with occasional 
interruptions, until after midnight, and sometimes until two o'clock 
in the morning. She enjoys her breakfast and dinner, but has no 
appetite for tea. 

She is very confident that when she was pregnant with her two 
living children, the gastric symptoms came on as with most women, 
in the morning' and not at night. And also that, in case of the two 
which she lost prematurely, the nausea and vomiting occurred, as 
in the present instance, during the eveniug and night. For this 
reason she dreads an impending abortion, and is fully persuaded 
in her own mind that it is quite impossible for her to go to " term." 
This conviction is almost confirmed by the dictum of hei former 
physician, who declared positively that it would be out of the 
question for her to carry her offspring beyond the fourth month. 

Upon careful digital examination, I found an evident deviation 
or displacement of the uterus. The os uteri was nearer the sym- 
physis pubis than natural, and at the Douglas' cul-de-sac there 
was a hard, globular tumor, which yielded to steady pressure in 
the direction of the sacral promontory, and finally passed upwards 
out of reach. This little manipulation afforded her great relief. 
She insists that the replacement of the womb has always palliated 

311 



31 2 THE DISEASES OF WOMEN. 

the gastric distress, and sometimes stopped it entirely for days 
together. 

This is an exceptional case. It is seldom indeed that the reflex 
gastric symptoms in the early months of pregnancy are so pro- 
nounced. I have, accordingly, chosen it as 

in?a e Hrp?egni C nc S y mptoms the tneme for a few practical remarks. The 
case is a typical one, which illustrates the in- 
timate relationship through indirect nervous communication, 
between the uterus and the stomach. This peculiar sympathy is 
shown in various ways. I have known a patient to vomit within 
five or ten minutes after, and in consequence of the application of 
the nitrate of silver to the uterine cervix. A sudden dropping 
down of the womb in some cases of prolapsus produces the same 
effect. In many cases of tardy labor dependent upon rigidity of 
the os uteri, emesis removes the cause of the delay by relaxing 
the cervix. For it often happens that, when delivery has been 
delayed for some hours, the sudden relaxation of the os is announ- 
ced by retching, and a desire to vomit. Ulceration of the cervix 
may indirectly occasion the most intractable vomiting. Bennet 
and others are of opinion that the worst cases of " morning sick- 
ness" are referable to this cause. Uterine displacements are 
known to produce it, and it is more than possible that the slight 
prolapse of the womb, which is incident to the first months of 
gestation may help to account for this very distressing symptom. 
In the example before you, the retroversion, which is tempor- 
arily induced by more or less of exercise upon her feet during the 
day, and which is relieved when the patient 
Retroversion a possible rests at night, is evidently the chief cause of 

cause of morning sickness. o ' J 

the retching and vomiting. When the fundus 
and body of the uterus topple over backwards, they not only press 
upon the anterior sacral or sciatic plexus of nerves, which is 
situated at the side of the rectum, but also upon the sacral ganglia 
of the great sympathetic. The hypogastric plexus is also impli- 
cated in the displacement. The ease with which the organ can be 
replaced, and the manifest relief afforded, are not only useful in 
the matter of diagnosis, but suggestive as to the postural treat-, 
ment proper for our patient. For, the mere prescription of a 
remedy, or remedies, to be given internally for the relief of the* 
gastric symptoms, is but a fractional part of the physician's duty 



THE DISEASES OF PREGNANCY. 313 

in a case of this kind. It will often happen, that by placing such 
a patient in a proper posture, and regulating her diet, as well as 
the time of eating her meals, and the amount and quality of exer- 
cise taken, we can accomplish more than by the most appropriate 
■constitutional means. The cause of the suffering is purely local, 
and the treatment should be partly, if not exclusively, local also. 
In less than a month, if the excessive vomiting and the dis- 
placement do not cause abortion, this woman's womb will pass 
out of the pelvic basin into the abdominal 

Abortion a contingent of . . -, . . , , 

retroversion of the gravid cavity, in order that it may undergo the proper 
development. If we can succeed in averting 
the contingency of miscarriage, (which is, perhaps, doubtful,) 
she may go on well to term. For when the womb has escaped 
from the lower pelvis, its liability to dislocation will be removed, 
and the proneness to gastric derangement cease. Provided the 
retroversion is not inveterate, the gastric disorder will be self- 
limited. 

The idea has long been entertained and advocated by obstetri- 
cal writers that, unless a pregnant woman has " morning sickness' ' 
if not excessive, morn- at some period of gestation, she will be apt to 
Aft tTretura at mghtTn miscarry, or perhaps to have a difficult and 
retroversion. dangerous labor at its close. Although there 

are frequent exceptions to this rule, many persons passing through 
pregnancy from first to last without any particular derangement 
of the stomach, and finally doing well, it nevertheless remains 
true, that its presence is a more favorable sign, if it be not extreme 
in degree or misplaced in the period of its recurrence, than its 
absence. From careful observation in this respect, I am led to 
conclude that the habitual return of this symptom at evening, or 
as sometimes happens, in the middle of the night, renders it a 
more serious and obstinate affair than when it comes in the early 
part of the day, whether before or after breakfast. 

While it is no part of my duty or desire to reflect unkindly 
upon my professional brethren, I must be emphatic in warning 
you against perpetrating the folly and wrong 
^fiorf u°ntlrrint\ v d' able which this patient's former physician commit- 
ted when he declared it impossible for her ever 
to carry another child past the fourth month. His opinion was 
not properly deduced from the facts of the case, and is, therefore, 



314 THE DISEASES OF WOMEN. 

fallacious. Because this poor woman had retroversion in the 
early stage of two successive pregnancies, and afterwards aborted, 
it by no means follows that a third or a fourth attempt to com- 
plete the process of gestation can not prove successful. If such 
a verdict were as harmless as it were unjustifiable, we would pass 
it by without further notice. But you are witnesses to the fact 
that it weighs down this patient's spirits like an incubus, and dis- 
courages her in the outset. Such dicta are inexcusable and mis- 
chievous. There are few circumstances that will warrant you in 
telling a woman that she cannot possibly go through with preg- 
nancy, and give birth to a living child. Daily experience proves 
that even the most learned and reliable practitioners are likely to 
be mistaken when they pass such a sentence upon their patients. 
The range of physiological possibilities is a wide one, and since: 
Nature will do as she pleases, it will be wise in us not to assume 
to limit her powers in this direction. 

Treatment. — The first indication presented is to restore the 

womb to its natural position. This may usually be accomplished 

by a species of vaginal taxis, pressure being 

How to replace the womb. _ 

made with one or more 01 the lingers against 
the body of the displaced organ in the direction of the sacro- 
vertebral angle. In order to be most efficient and least harmful, 
this operation should be performed in a slow and cautious, not in 
a rapid and careless manner. The desired result will be facili- 
tated by calling gravitation to our aid. For this purpose, in most 
cases, it may suffice for the patient to lie upon her side, or better 
still, upon her abdomen. We may, however, find it best to place 
her in the prone position upon the knees and breast, over one or 
more large pillows, as recommended in the treatment of prolapse 
of the funis, and for the correction of presentation of the face,, 
side and shoulder. It may also be necessary to introduce the 
finger, or some other instrument, into the rectum in such a man- 
ner as to aid in replacing the uterus. Gariel's air-bag may be 
passed into the bowel behind the displaced organ, and afterwards, 
so inflated as to lift the fundus, and compel the womb to corre- 
spond as it should with the axis of the superior strait. Or you 
may employ this little instrument, devised by my friend, ProL 
Guernsey,* which is admirably fitted to fill the same indication. 

* Vide Guernsey's Obstetrics, etc., 1867 ; page 16. 






THE DISEASES OF PREGNANCY. 315 

In using this instrument, Dr. Gr. recommends that after the 
bladder and rectum have been emptied, " the patient should be 
placed on the bed, near its edge, upon her knees and elbows, so 
that the force of gravity may assist in the reduction. The ball of 




Fig. 29. Dr. Guernsey's Uterine Repositor. 

the instrument, well lubricated, is to be brought to the anus, with 
the convex surface of the rod upwards, then gently pressed until 
within the sphincter, when the handle should be slightly elevated,, 
so as to bring the ball against the anterior wall of the rectum. 
The instrument is now to be firmly and carefully pressed up the 
rectum, when the ball will elevate the fundus, — care being taken 
to raise the handle more and more as progress up the rectum is 
made ; and presently the uterus will regain its normal position 
immediately posterior to the symphysis pubis. 

In all cases of uterine displacement incident to pregnancy, and 

whether for purposes of exploration or of treatment, you should 

carefullv abstain from the introduction of any 

The uterine sound as _ J J 

a means of reducing instrument whatever through the canal of the 
the dislocation. cervix into the uterine cavity. Such an opera- 

tion would be almost certain, sooner or later, to be followed by 
abortion. And I flatter myself that no member of this medical 
class would willingly commit the crime of murder, even for the 
sake of curing a case of prolapsus, or of retroversion of the womb ! 
I have known a physician, however, who, through cupidity and 
ignorance, found it convenient to diagnosticate many examples of 
the latter displacement in pregnant females, and afterwards to 
reduce the dislocation by means of the uterine sound — a most 
cruel and unwarrantable expedient. 

But simply to replace the oro-an in such a case 

Postural treatment. . r ^ . n , ™ . 

as the one before us is not ahvays sufficient* 
Unless we provide against a recurrence of the displacement, more 




31.6 THE DISEASES OF WOMEN. 

especially when the patient assumes an upright position, the in- 
creased size and weight of the womb will bring- it down again. 
To obviate such a result, and thus indirectly to control the gastric 
symptoms, she should remain in the horizontal position upon the 
bed or sofa, and should lie either upon the side or upon the abdo- 
men. If she can keep off her feet altogether until such time as the 
uterus has ascended into the abdomen, the vomiting will be greatly 
relieved, and perhaps cured, and, what is still more important, the 
chief danger of abortion will also be averted. 

It is only now and then that a pessary is of real utility in the 

uterine deviations contingent upon pregnancy. The watch-spring 

pessary, covered with rubber, 

The pessary. . ._ " . , 

aviII sometimes answer a good 
purpose temporarily, and is less objectionable 
than most others. Either of the stem pessaries 
would be more likely to cause than to prevent a 
miscarriage, and moreover they are not suited to 
cases of retroversion. FlG . 30> watch-spring 

In two similar instances I have succeeded in Pessary, 

keeping the womb in situ by the introduction of a small sized air- 
pessary, to be then inflated, in the posterior and superior portion 
of the vagina, in such a manner as to prevent the body and fundus of 
the organ from falling towards the coccyx. When distended with 
air, this rubber bag becomes a species of cushion against which the 
uterus may rest without injury, and indeed it can do no possible 

harm to the soft parts. Nor is it half so 

liable as instruments that are made of more 

solid materials, to stimulate reflex uterine 

contractions, and thereby to excite an 

f abortion. Some practitioners prefer 

fig. 31. Cutter's Pes^. Hodge's lever, or Cutter's pessary in this 

as in other cases of retroversion. If judiciously used, it very 

rarely happens that the means which I have indicated Avill not 

serve to replace the womb and to keep it in position. A few cases 

are recorded in which the displacement has per- 

Ketroversionmay ^ted until the end of gestation. Where the 

persist until terra. n 

retroversion is inveterate, and in case of an emer- 
gency, it has been thought expedient sometimes to promote the 
evacuation of the uterine contents by rupturing the amniotic sac 




THE DISEASES OF PREGNANCY. 317 

through the uterine cervix, or by the operation of paracentesis 
uteri, as first recommended by the celebrated Dr. ,Wm. Hunter. 

In a report upon the retroversion of the gravid uterus, read 
before the Obstetrical Society of London, by Dr. W. Tyler Smith*, 
you will find the following instructive case : 

" I was consulted in August 1859, by a lady, a patient of Di\ 
Duigan, of Gainsborough. She Avas the mother of two children,, 
and, in the previous May, had a miscarriage, which left her in a 
very weak state. She had lost blood largely, and had since been 
irregular at the periods. Her chief complaint was of a distressing 
pain at the bottom of the back, and the least attempt at walking 
or exertion produced faintness. On making a digital examination, 
the uterus was found to be retro verted, the fundus hanging upon 
the lower part of the rectum, and so enlarged as to make me be- 
lieve that pregnancy existed. She remained in town about a 
month; and the increase in the size of the uterus in this time con- 
verted the belief into certainty. There is no other condition in 
which the increase of the gravid uterus in the early months can 
be so readily estimated as in retroversion. The globular fundus 
is so perfectly within reach of the finger, as to render it possible 
to measure its increase with a precision which cannot be obtained 
when the uterus is in its natural position. In this case, the fundus 
could be lifted from the rectum, so as to afford temporary relief, 
but it Avould soon return to the position of retroversion. Acting 
on this hint, I introduced an air-pessary of considerable size which 
gave great relief, and enabled her to move about to an extent 
which had been previously impossible. With the air-pessary the 
uterus remained in a state of semi-retroversion. She continued 
to wear the instrument, with great comfort, for upwards of two 
months, and only left it off when quickening and the movements 
of the child made it certain that the uterus had risen out of the 
pelvis. She was delivered in April last of a living child, and 
carefully rested after her confinement, lying as much as possible, 
in the prone position. In this case, the pelvis was a large size, 
and it is the only instance I have seen of persistent retroversion 
in the gravid state, in which there was no vesical symptom what- 
ever. I have seen this patient twice since her delivery. The first 
time there was no sign of retroversion, but the second it had re- 

*Trans. of the Obstetrical Society of London; Vol. II.. page 297. 



318 THE DISEASES OF WOMEN. 

turned to some extent, and I advised the use of the air-pessary 
again." 

CHOREA DURING PREGNANCY. 

Case. — Mrs. S., primipara, is twenty-five years old. Her 
menses appeared at thirteen and a half years ; but, without realiz- 
ing what might follow in consequence, she took a cold bath at 
the time and afterwards suffered from spasmodic dysmenorrhcea. 
At the age of sixteen she had an ulcer on the left leg, over the 
tibia, which began as a blister and spread extensively, finally in- 
volving the knee. The ulcer was healed, after two months treat- 
ment, by topical applications. The cicatrix has since been the 
seat of tingling sensations, which were aggravated by cold. 

For three years past this patient has not menstruated more than 
six or eight times in twelve months. The flow has always been 
painful. She is now eight months advanced in pregnancy. At 
the first month she began to have choreic twitchings in the left 
hand and arm ; afterwards the corresponding foot and leg became 
affected in the same way. Then there was a tingling in the left 
side of the face and head, and at the second month the muscles of 
the same side of the face began these grotesque movements. 

At the fifth month the choreic twitchings changed sides, the face 
excepted, in consequence of her being put into a cold wet-sheet 
pack. Since that time the voluntary muscles of the right leg and 
arm, and of the left side of the face have also been affected. 

With the dysmenorrhcea the left breast used to become swollen 
and very tender, but the right one always escaped. From the 
date of conception, however, the left breast has not been painful. 

Although she inherits a predisposition to rheumatism, she says 
she has been very careless in not protecting herself from changes 
of the weather. She has often worn damp clothing, and gone 
for many hours with wet feet. Of late she has been very nervous 
and sleepless, talks at night and suffers from the most frightful 
dreams; but the spasms are suspended during sleep. The appe- 
tite is good, but, since the chorea set in, the bowels have been invet- 
erately constipated. At evening the ankles are puffed, but in the 
morning they are not so. She has at times severe pains in the 
back and in the left side, and the spinous process of the fourth 
dorsal vertebra is tender to pressure. She never had the chorea 
while a child, nor does she know of a case in her family history. 

Technically speaking, this is an example of chorea gravidarum. 
Waiving the discussion of certain physiological questions con- 
nected with the subject of chorea, we shall find that its clinical his- 
tory is full of interest. You may have supposed that chorea was 
exclusively a disease of childhood, which, in the case of girls espe- 






THE DISEASES OF PREGNANCY. 319 

daily, terminated at puberty. But here it complicates pregnancy 
in a woman who is twenty-five years old. In most cases of this kind, 
and they are not very common, you will discover that the patient 
has had the chorea when a child. Very likely the former attack 
ceased with the regular establishment of the menstrual function, 
for, as a rule, with young girls, it is a self-limited affair. But 
this woman insists that she never had anything like it before. 

Etiology. — Not unfrequently chorea is hereditary. I have seen 
it in three generations of children in the same family. Some 
times, by a species of atavism, it skips one generation and appears 
in the next following. And, even where the disease does not 
become fully developed, there is often a latent predisposition to 
it, in which certain exciting causes may precipitate an attack. 

Nature. — Such a predisposition is sometimes secondary upon 
other diseases, more especially upon rheumatism and hysteria. 
As long ago as the year 1821, Dr. Copland, 
author of the Dictionary of Practical Medicine, 
drew attention to the fact that chorea may be, and frequently is, 
a- sequel of rheumatism. In the case of children, I am confident 
that there are numerous exceptions to this rule, which at one 
time was thought to be almost universal. But with women du- 
ring gestation, a large proportion of those who have had chorea 
have also had sub-acute rheumatism. In the case before you the 
nervous symptoms, which have been charged to an "insanity of 
the muscles," and which are so pronounced while I am speaking, 
are engrafted upon the rheumatic diathesis. 

This form of chorea may spring from anaemia, or from chloro- 
sis. There is no doubt that the impoverished condition of our 
patient's blood, and the consequent lack of nu- 
trition of the nerve centres, has helped to pro- 
duce this unfortunate result. For the growth of the foetus in 
ntero drains the blood of its best constituents, and predisposes the 
mother to nervous affections of various kinds. 

This case is in evidence that dysmenorrhoea may develop a bias 
toward spasmodic affections, which shall outlive its own existence. 
The local spasm of the uterine neck, which caused the pain at the 
month, and sometimes stopped the periods altogether, worried the 
nervous system into this peculiar condition, which is closely akin to 
oonvulsibility. Hence an acquired susceptibility to such exciting 
causes as may bring on the attack. 



320 THE DISEASES OF WOMEN. 

These exciting causes cannot always be ascertained. Fright is. 
the most common of them all. Woodman cites a case in which a 
pregnant woman was seized with chorea from 
thinking that her husband was killed; and Rom- 
berg and Helfft each a case in which it was caused by the shock of 
falling into the water. This kind of psychical shock has the same 
effect upon adult women who are inclined to chorea that it has 
upon children. I have seen a case in which chorea was induced 
in a young woman, who was only one month advanced in preg- 
nancy, by a terrible scolding which her mother gave her. Wo- 
men are sometimes worried into this state by the dread of havings 
it known that they are pregnant. 

The presence of the foetus in utero is an incident exciting cause 
of a peculiar kind. In certain very sensitive women an ovum of a 
fort-night or three week's development may be sufficient to excite 
such reflex spasms of the voluntary muscles, as you see in our pa- 
tient. The growing germ is a more or less constantly acting cause. 
If chorea begins, as it did in this woman's case, quite early in the 
period of gestation, it will most probably continue until its close; 
for while the cause remains, the effect must continue, and it will 
not cease until the gravid uterus has been emptied of its contents. 
All the reflex phenomena, connected with pregnancy, if they arc 
serious, are subject to this rule. Sometimes, although rarely, cho- 
rea is also a post-puerperal affection. 

As with children, it may follow the repercussion of the measles,, 
or of various eruptions ; and it is not improbable that this acci- 
dent may have been a factor in the case before us. 

Chorea is more common with primiparse than with those who 

have had children before. One attack does not, however, give 

exemption from another. There are those who 

In primiparae. . v „ .. _ . 

have chorea in a modified form for two or more 
successive pregnancies; and per contra, as with puerperal convul- 
sions, most women who have it at all, have it but once. In this 
matter very much depends upon the external circumstances, as 
well as upon the morbid tendencies to which the patient may have 
been subjected. 

Symptoms. — The symptoms are identical with those belonging 
to the same disease in children. The irregular contractions and 
twitchings of the voluntary muscles, which defy the will of the; 









THE DISJ'ASES OF PREGNANCY. 321 



patient, are quite distinctive. These movements are almost al- 
ways unilateral, or hemic horeic, and the left side is more fre- 
quently affected than the right. Sometimes, however, either for 
an unknown reason, or in consequence of something that has been 
done for her relief, as with the wet-pack in this case, the lesion is 
shifted to the opposite side. Or the spasm may affect first one 
side and then the other, alternately. The more pronounced the 
rheumatic bias, the more likely is the disease to travel from one 
set of muscles to another, and finally to become general. 

In exceptional cases the spasms may be limited to one or both 

the legs, to the muscles of the abdomen, to those of the face and 

neck, or of the hands and finders, the larynx, 

Localized chorea. , , , -,. i n ,.1, "~ -,, , 

and the diaphragm ; and still more rarely to the 
heart, giving rise to what has been denominated " cardiac chorea." 
Whatever their location, and however severe they may be, these 
spasms are suspended during sleep. 

There is a phase of morbid action which, in some of these cases 
of chorea gravidarum, is both curious and suggestive. At the 
outset of the attack the brain is not always implicated, but after 
a little the cerebral symptoms show themselves and keep on in- 
creasing in a compound ratio until the case ends, either with abor- 
tion or with labor at term. This gradual and progressive impair- 
ment of the mental faculties is more marked in the case of wo- 
men than in children who have the chorea. They become irritable, 
peevish, capricious and unhappy; they lose their memory, grow 
melancholy, threaten suicide, and are full of gloomy forebodings. 
Not unfrequently they are subject to attacks of delirium, and may 
even become maniacal. 

Dr. Barnes (Transactions of the Obstetrical Society of London, 
vol. x., p. 180,) is assured of the probability that the chorea 
causes the mental disorders. " This it does by the repeated shocks 
that at first stun the nervous centres; these shocks are equivalent 
to concussions, they exhaust and divert the nervous force, and af- 
ter a time impair the nutrition of the nervous substance. This 
hypothesis is perfectly consistent with the clinical facts, that the 
cerebral disorders are progressive in proportion to the duration 
and severity of the chorea, and if not too far advanced, undergo 
Amelioration with the decline or cessation of the chorea." 

Although, in its nature, chorea is essentiallva convulsive affec- 



322 THE DISEASES OF WOMEN. 

tion, you should remember that it holds no clinical relation to 
puerperal eclampsia, epilepsy, catalepsy, or coma. If this patient 
reaches term without accident, she will not be more likely than 
other women to have convulsions, either before or after her deliv- 
ery. She may reach the very acme of hysterical excitement and 
apprehension, but it would be quite exceptional for her to have 
genuine convulsions. 

Prognosis. — Cases of this kind usually get well, but not speed- 
ily, nor as the direct consequence of medical treatment. In its 
slighter forms the chorea may be relieved and possibly cured be- 
fore the termination of pregnancy. Such a result is the more 
likely to follow if the attack was caused by a slight shock, which 
has not been repeated; if it is idiopathic and not secondary upon 
another disease, neither upon a depraved condition of the blood, 
nor an enfeebled state of the general system ; if the uterus is not 
too irritable, or intolerant of its contents ; and if the patient has 
never had the chorea before. 

The rheumatic complications are more lasting and dangerous. 
Iii some of the worst cases there are cardiac lesions, which, al- 
though they may have been latent before, have been lashed by the 
choreic convulsions of the heart, into a really serious condition. A 
mere irritability and irregularity of the heart's action, palpitation 
and precordial oppression, should not discourage you; but if you 
recognize the systolic bruit at the apex of the heart, and above 
all, the physical signs of valvular endocarditis, in a rheumatic 
subject with chorea, the prognosis should be guarded. 

The anaemic murmur, which is heard along the course of the 
carotid and other great vessels, is not so serious a symptom. Nor 
in general, are the signs of hypertrophy of the heart (which is 
more frequent in pregnant women than is generally supposed,) 
necessarily g-rave in their character. 

The cerebral symptoms do not afford a reliable criterion of the 
gravity of the disease. They are the epiphenomena which are 
more alarming than serious. It is only when they depend upon 
an organic disease of the brain, or in very rare instances, upon 
cerebral embolism, that they are of fatal significance. As a rule 
they disappear after delivery. 

Occasionally the muscular symptoms are so severe, and the gen- 
eral illness is so marked, that a crisis is extemporized by the spon- 



THE DISEASES OF PREGNANCY. 323 

taneous coming" on of labor. Xature takes this measure to get rid 
of the exciting cause of the trouble, and to put an end to the symp- 
toms. The choreic contractions may seize upon the womb in such 
a way, and so forcibly, as finally to bring on the proper expulsive 
efiort. Hence a liability in these cases to abortion and to prema- 
ture delivery. But, if the woman reaches the period of gestation 
without having had such a mishap, the chorea is finished as 
abruptly and as completely by the birth of the child as intermittent 
fever ever was by natrum murtaticum. This is a rule to which 
there are few exceptions. 

This form of chorea is sometimes fatal. Dr. Barnes has com- 
piled the history of fifty-six cases of chorea gravidarum, of which 
seven died. The post-mortem lesions were not 

The fatal form. . , . ., . ■ ■ ■« 

constant, or in any sense characteristic, rev- 
haps the most frequent of them was the existence of incidental, 
polypoid vegetations, or fibrin-beads, which had gathered upon 
the mitral valve of the heart. It is possible that some of these 
little growths may have been detached and carried with the blood 
into the smaller vessels, finally causing death by embolism. 

Treatment. — The first thing to do is to put the patient, as much 
as possible, beyond the reach of all those influences which tend to 
perturb and to derange the nervous system. For, she is, of neces- 
sity, very impressible to the little things Avhich are of no account 
in themselves, and ot which a well person would take uo notice. 
Her surroundings ought to suggest a calm and quiet demeanor, and 
everything in her daily life should be as grateful and pleasant as 
possible. Her diet, society, occupation, sleep and exercise, should 
all be tuned to this key. If it is otherwise, you need not wonder 
if the most fitly chosen remedies shall fail to effect. These remarks 
apply especially to those who have had the disease before. 

My own experience leads me also to place great reliance upon 
the kind and quality of the food that is chosen. In the majority 
of cases there is an evident lack of nutrition. These patients need 
to be ted and fortified against a debility, of which the nervous 
spasms, like a neuralgia, are the obvious sign. These convulsive 
movements often increase as pregnancy advances, because the blood 
becomes more and more deficient in its nourishing properties. If 
the drain is not stopped, or rather, if its effects are not counter- 
acted by a proper alimentation, the disease will grow worse instead 



324 THE DISEASES OF WOMEN. 

of better. A mixed diet should be allowed. Let it consist of 
milk, eggs, game, oysters, and other sea-food, good, wholesome 
bread and butter, and such other healthful articles as may be avail- 
able, and as will suit the taste. The malt liquors are sometimes 
very useful in this connection ; but it is best to interdict the use of 
tea and coffee. For the latter we may substitute chocolate, or the 
alkathrepta. This part of the treatment is so important, that it 
should not be overlooked, even in the mildest cases. 

There are nervous conditions which simulate chorea, that yield 
readily to such remedies as belladonna, ignatia, coffea, nux vomica, 
agaricus, and cuprum, under appropriate indications. These states 
are temporary, and often depend upon avoidable causes. They are 
easily cured. 

But confirmed cases require more skillful management. The 
spasms are likely to be inveterate. If they are caused by fright, 
ignatia, opium, calcarea carbonica, or cuprum may be called for. It 
is said that cuprum aceticum has cured this disease when it was 
occasioned by seeing another person in the fit. 

If the chorea is traceable to suppressed eruptions , this fact pre- 
sents a strong indication for cuprum aceticum, calcarea carbonica 
causticum, or sulphur. 

If the original exciting cause is in the uterus, the remedies which 
act upon that organ in such a manner as to control its local spasms 
and its reflex sympathies, will surely be required. Among these 
are belladonna, pulsatilla, sepia, sabina, gelsemium, veratrum 
viride, and caulophyllin. You cannot go wrong in cases of this 
kind if you give either of these remedies under precisely the same 
indications for which you would prescribe them in threatened 
abortion. For if, by this means, you can avert the miscarriage, 
you will have found the proper medicine for the relief, if not for 
the cure, of the choreic symptoms. 

Where the symptoms have their root in the rheumatic constitu- 
tion, we must prescribe accordingly. Rhus toxicodendron, macro- 
tin, or gelsemium, may either of them be required, to correct 
this peculiar bias. I have the greatest confidence in the gelsem- 
ium, more especially because with it I have been very successful 
in curing the chorea when it has followed or complicated rheuma- 
tism in children. Excepting in confirmed organic disease of the 
heart, it cures most of the incidental cardiac lesions that we find in 



THE DISEASES OF PREGNANCY. 325 

cholera, and controls the nervous and spasmodic symptoms like a 
charm. I prefer to give it in the second decimal dilution, taking 
care to watch its effects very closely. 

How to interpret the mental symptoms is not airy easy prob- 
lem. What they signify and what they indicate, is something as 
difficult to decide as it is in a case of hysteria. Your best plan 
will be to place your reliance upon such of them only, as are not 
incidental and illusory. At the same time, you must be careful 
not to underate the importance of such as, at first sight, may seem 
to be trivial. Fortunately, the remedies which are most likely to 
be required for the cure of the choreic symptoms proper, will, in 
general, be equally applicable for the relief of the cerebral compli- 
cations. 

In a few instances recorded, these cerebral complications have 
however been of such an alarming nature as to justify a resort to 
the induction of premature labor. But, probably because this ex- 
pedient has been too long deferred, these cases have very generally 
died. It is possible that, in consequence ot deep-seated lesions of 
the cerebre-spinal centres, the evacuation of the gravid uterus might 
fail to arrest the disease. 

Anaesthetics are admissible only as temporary palliatives. They 
are suited to the worst cases, and their use should be restricted to 
the later weeks of pregnancy. Sulphuric ether is safer and better 
than chloroform. Neither should be administered by the patient 
herself. A pleasant and effective compromise may sometimes be 
made with those who clamor for something of this kind by putting 
twenty drops of sulphuric ether in half a glass of water and letting 
them take a teaspoonful every five or ten minutes, until they are 
quiet. Bathing and dry rubbing, if agreeable to the patient, may 
also be of service. Electricity should be used, if at all, only with 
the greatest care, in the chorea of pregnant women. 

This woman will take gelsemium 3, once in four hours. [This 
patient was delivered with the forceps, in the hospital, in the 
presence of several members of the class, on the eve of January 
7th, 1875. Her labor was natural. The anaesthetic, ether, acted 
well, and she had no sign of a convulsion. The choreic spasms 
abated, and in a fortnight she was discharged, cured.] 



LECTURE XX. 

ABORTION WITH MISPLACED PAINS. 

Abortion with misplaced pains; the ''habit" of aborting; intermittent abortion ; the 
sequelae of abortion. 

Case.— In consequence of over-exertion, Mrs, G., aged 30 r 
aborted at the end of the third month. She had twice before mis- 
carried at the same period of pregnancy. Immediately after vio- 
lent exercise at house-cleaning, she began to flow slightly, and to 
experience an occasional sharp pain in the left hypogastrium. After 
a restless night she awoke at 6 a. m. with an acute, lancinating 
headache. This pain in the head was accompanied by an extreme 
soreness and tenderness in the nape of the neck. The pupils were 
dilated to nearly the whole extent of the iris. She complained of 
photophobia, with a shower of sparks before the eyes, and in a 
species of semi-delirium declared herself in the immediate neigh- 
borhood of a tearful conflagration. These later symptoms would 
disappear in the intervals between the paroxysms -of headache. 
When the pain in the head returned, she would scream and shriek 
and beg to be held firmly, in order that no terrible accident might 
befall her. These paroxysms returned every ten minutes for about 
two hours, or until I came and relieved her with a few doses of 
belladonna 3d. Upon examination, the os uteri was found but 
slightly dilated. The pain subsided, and finally ceased. 

Tiie same tram ot symptoms came on the second morning at six 
o'clock. They were, however, less violent in degree and of shorter 
duration, lasting in all not more than an hour. The os uteri was 
a little more patulous. The passive flow continued, but there were 
no uterine pains whatever. 

The third morning she had ha-f a dozen of the same paroxyms 
of pain in the head. They were repeated once in five or six min- 
utes, and were as severe as those of the first day. In the intervals 
she was found to be bleeding much more freely. 

The stomach had become exceedingly irritable, and she vomited 
frequently, each effort at emesis serving so perceptibly to increase 
the hemorrhage that the patient remarked it herself. The head- 
ache passed off, but during the clay she had two pretty severe 
uterine pains of an expulsive character, and became really quite 
ill. Early next morning regular labor pains commenced and con- 
tinued so that in an hour and a half all was over. The head and 
nervous symptoms vanished as soon as the proper uterine contrac- 



THE DISEASES OF PREGNANCY. 327 

tions began. The fifth morning the headache did not return. She 
made a good recovery. 

Perhaps a majority of cases of accidental abortion are caused 
by undue or unusual muscular exertion. Lifting, scrubbing, over- 
reaching — as in hanging a picture, carrying a 
Abortion from over- chM ft j- distail c e hurriedly— as when in 

exertion. ° J 

haste to reach home or to take the train, run- 
ning the sewing machine for consecutive hours and days, horse- 
back riding, or climbing steep and difficult stairs, as for example, 
to the cupola of the city hall, have caused the uterus to expel its 
contents prematurely. 

You will not, however, understand me to say that these causes 

are invariably followed by such unfortunate consequences. Far 

from it. In many, and probably most pregnant 

Remarkable tolerance th - remarkable tolerance of 

of exercise. 

fatigue and even considerable muscular effort, 
if it be moderately and habitually practised. There are those in 
whom it would be impossible to bring on abortion by any such 
means. But in the majority of cases such a mishap is more easily 
induced. This is especially true of women of sedentary habits, 
who ordinarily take very little exercise, whether indoors or out, 
but who, under peculiar temptation or provocation, exceed the 
bounds of prudence, and overdo and injure themselves. In the 
matter of taking proper exercise, as in everything they do, these 
subjects are fitful and capricious. In them a sudden strain, or any 
unusual effort, conjoined with extraordinary nervous excitement 
and impulse may work mischief that might have been averted. 

Add to this, that if the woman has aborted once or twice already, 
and is, therefore, predisposed to this accident, these causes are 

more harmful, and we have the etiology of this 
aborting" 11 " 1 ° f class of cases plainly before us. The habit of 

aborting at a particular date of pregnancy also 
increases the clanger from this variety of accidental causes ; for 
there are women who miscarry at a certain time with almost as 
much regularity as they menstruate when they are well. And, 
although this result may happen at any period of gestation, it is 
extremely liable to occur at the end of the third month. This 
clinical fact is confirmed in the case just now detailed to you. 
Our patient had already miscarried twice at the twelfth week, 



328 THE DISEASES OF WOMEN. 

and now, with the arrival of the same period, over-exertion in 
house-cleaning caused a slight uterine flow, and pains, which 
resulted in the loss of the embryo. You should not fail to observe 
that this indiscretion and excess on her part was more mis- 
chievous at this particular time than it might have been at any 
other. 

Even a slight flow of blood from the gravid uterus, and espe- 
cially if it be accompanied by pain in either hypogastrium, or 
about the loins, may betoken a miscarriage. Under these circum- 
stances the symptoms of impending abortion do not differ, in any 
essential particular, from those which date the appearance of the 
menstrual discharge. We are naturally suspicious of them, how- 
ever, and solicitous concerning their interpretation and results ; 
for their continuance signifies an interruption in the process of 
intra-uterine development, and the possible sacrifice of the off- 
spring. 

But the chief peculiarity ot this case was the periodical and 
regularly recurring headache. This was a good example of inter- 
mittent abortion.* The headache took the place 

Intermittent abortion. _ . . ... 

of the uterine pains, came every morning lor 
three successive days, continued for a given time, and then left. 
The paroxysms, which were distinctly pronounced, came and went 
with the regularity cf labor pains. And they increased in fre- 
quency each day. Meanwhile, there Avas no expulsive uterine 
effort, or at least none of a painful or positive character. By and 
by the flow increased, and the stomach became implicated. Vom- 
iting" ensued. This was a certain sign that the os uteri had beg-un 
to dilate more freely and rapidly. The principle obstacle to deliv- 
ery, and the indirect cause of the headache, also, were removed as 
soon as the cervix Avas sufficiently relaxed for the escape of the 
contained embryo. Proper uterine contractions succeeded. The 
real labor Avas short and decisive. The headache vanished, haem- 
orrhage ceased, and our patient made a good recovery. 

Treatment. — There are several methods by which this case 
could have been brought to a successful termination. The ques- 
tion to decide was, which is the more safe and expedient. I might 
have given this Avoman a strong dose of ergot, and finished her 
labor abruptly, by forcing the uterus to expel its contents through 

*Vide U. S. Medical and Surgical Journal, vol. iv., p. 75. 



THE DISEASES OF PREGNANCY. 329 

the slowly dilating os. Or, perhaps, a powerful cathartic Avould 
have produced a similar result. Or an emetic might have unlocked 
the cervix, with the mysterious key of reflex action. Or sitz-baths, 
or the colpeurynter, might have brought about the same end. Or 
.an old-fashioned dose of morphine, or perhaps of quinine, might 
Jiave arrested the headache, until such time as the gradual expan- 
sion of the lower segment of the womb should permit the proper 
pains to come on spontaneously, and terminate the delivery. 

But the belladonna was a more appropriate, specific, and satis- 
factory remedy. Not only did it relieve the headache, which, as 
I have said, was indirectly due to the rigidity of the uterine neck, 
but it also relaxed the fibres of the unyielding cervix — which is 
slow to yield before the fourth month — and thus removed the 
cause of the suffering and the delay. It was appropriate for the 
pain in the head, because it was specifically adapted to remedy 
the condition of the cervix, upon which it depended, and of which 
it was the consequence. It harmonized the nervous sympathies 
^existing between the body of the womb and its inflexible outlet. 
It charmed away the impending danger to the brain, and permit- 
ted nature to complete the delivery with the least possible risk to 
the health and welfare of the patient. 

One of the best remedies that I have ever given in "intermit- 
tent abortion" is gelsemium. It seems adapted to the same 
general symptoms which call for belladonna, with the added 
complication of a paroxysmal recurrence of the symptoms that 
threaten to precipitate the extrusion of the ovum. The repetition 
of the paroxysm may have a regular type, like a fit of the ague, 
with a distinct interval, and may perhaps be accompanied by a 
discharge of mucus or of amniotic fluid. 

Where it is desirable to centre the scattered, or wild pains, 
upon the womb, and to finish the delivery, because in any event 
it is inevitable, caulophyllin is the remedy. 

THE SEQUELAE OF ABORTION. 

This patient was brought to the Clinic by my friend, Dr. W. 
W. Wilson, whose notes of the case I will read you. 

Case. — Mrs. , aged 39, English the mother of two children, 

lias always enjoyed good health until now. She has never been 



330 THE DISEASES OF WOMEN. 

troubled with female weaknesses of any kind, and never aborted 
before. She became pregnant during the latter part of April, and 
by the advice of an old midwife, took vaginal injections of warm 
water twice daily, for the purpose of promoting an easy labor at 
term ! On the tenth of June (at the sixth week), she came by 
railway from Indianapolis to Chicago. The next morning after 
her arrival, not having any warm water convenient, she took an 
injection of cold water instead, and this was applied with a com- 
mon rectal syringe. The shock w T as such that she fainted, and in 
a few minutes aborted, everything coming away with a gush. 

A physician was called in, who arrested the flow entirely, and 
the next day she felt so well that she did the washing for the 
family. That night she was seized with cramps and great pains 
through her bod}^ and limbs. Another doctor came, who said 
that she had inflammation of the bowels, and treated her accord- 
ingly. Since that time she has had four other physicians in turn, 
one of whom treated her for neuralgia of the liver (!), another 
for dropsy, a third for enlargement of the womb, and the last for 
dyspepsia. 

I was called Aug. 31, and found her in great pain and distress, 
respiration labored, pulse 125, feverish and talking incoherently. 
The pains were paroxysmal, like those of labor, but were con- 
fined to the left ovarian region. On examination, I found the 
uterus and vagina normal, except that there was a-slight, whit- 
ish discharge from the os uteri. Ordered pulsatilla 2 ° ° every two 
hours, and the local use of the extract of hamamelis. 

Sept. 1. Much easier. The pains have almost entirely ceased. 
Bell. 200 . 

Sept. 2. Still improving, but restless and cannot sleep. Con- 
tinue the belladonna, but in addition to take three doses of 
coffea 30 between 4 and 10 p.m. 

Sept. 3. Husband reports his wife better. Slept well all night. 
Continue the same remedies. 

Sept. 5. Found my patient sitting up and relatively comforta- 
ble. Bryonia 200 every three hours, and zincum valerianicum 3 
dec. a powder at night. 

Sept. 8. The menses came at 10 A. M. Says she is well, but 
very weak. China 200 every three hours. 

There is no single respect in which women differ more decidedly 

than in the readiness with which they abort. With some the 

slightest causes will induce a "mishap." A 

Causes of abortion. . , . -, . . , . -, 

misstep, a rough ride in a carriage, climb- 
ing stairs, a long walk, a severe cold, coughing, sneezing, 
an attack of dysentery or diarrhoea, nausea, dysuria, a severe 



THE DISEASES OF PREGNANCY. 331 

toothache, mental anxiety, or even jumping out of bed sud- 
denly, have been known to cause it in those who were very 
susceptible. On the other hand, there are some women, who, no 
matter what they do, or suffer, are in no possible danger of mis- 
carrying. They incur every risk without the least concern, or if 
so wickedly disposed, m^j try every means to induce an abortion, 
but without effecting it. The former are often disappointed in 
being unable to carry their offspring to term ; but sometimes take 
advantage of their idiosyncrasy to put an end to intra-uterine de- 
velopment. The latter are often victims of their own or others' 
temerity in trying to interrupt the wonderful process of gestation, 
and thousands of them suffer the remote consequences of such 
conduct in the form of uterine diseases which are sometimes en- 
tailed upon them for life. 

But nature has thrown certain safeguards around pregnant wo- 
men which generally exempt them from harmful contingencies, and 
help them to pass through the ordeal of mater- 
Toleration of injuries n i t y w ^^ less of danger and risk than you 

during pregnancy. J o J 

would at first suppose. As pregnancy ad- 
vances she develops a species of toleration to processes that are 
new and peculiar. She even counteracts and antidotes the mis- 
chievous interference of doctors of every grade, and nurses of all 
sorts, with her prerogatives. In this woman's case, the warm 
water injections happily did no harm. She could bear them with 
impunity. But the shock of the cold water, and especially when 
taken so soon after the journey, caused an almost instantaneous 
abortion. Perhaps she might have taken this injection at another 
time without any ill effect ; but, the probabilities are that while 
the habitual use of the warm water developed a toleration for it, 
the cold application could not be borne at all without mischievous 
results. 

I regret to say that there are physicians who do not regard an 
abortion at the early period of six weeks as an affair of the least 

consequence. They will tell you that prior 
tion°ist histries ° f the Abor " to quickening the embryo is not alive, and 

that there is no particular necessity for min- 
istering to its welfare or for shielding it from harm. But let 
me say, that the moment the ovum escapes from the Graafian 
ibllicle, that moment it ceases to be a part of the maternal organ- 



332 THE DISEASES OF WOMEN. 

ism. This is as true in case of fecundation as it is in menstruation. 
Arrived in the uterine cavity, the egg is no more a part of the 
mother than is the egg of the bird when laid in its nest to await 
future development, or that of the snake when dropped into the 
grass before being fertilized. It represents a separate organization, 
which, although incapable of maintaining a separate existence, is 
as really independent as the infant at birth, or its father at forty. 
Once the conditions for conception are supplied, and the vital- 
izing portion of the semen masculinum has impressed itself upon 
the ovum somewhere along the course of the 

The embryo is alive. 

generative intestine, the first step in the repro- 
ductive series has been taken. From this time forth, whatever 
imperils the integrity of that germ, implicates life ; and whoever 
intentionally intercepts the wonderful changes incident thereto, 
unless to save life, is a veritable murderer — no more and no less ! 

Whether prior or subsequent to the formation of the placenta, 
the dependence upon the mother for subsistence is substantially 
the same. No one familiar with the organization and function of 
the chorion can doubt this. The physical laws that regulate the sup- 
ply and waste, the nutrition and detritus of germ-life r embryonic 
life, and foetal life, are identical, and there is nothing in the mode 
of their operation which could lead us to infer that from the mo- 
ment of fecundation, the whole process of intra-uterine develop- 
ment is not of the greatest importance. 

It is no argument against the vitality of the smallest embryo, 
that direct vascular and nervous attachments between it and the 
endometrium have never been demonstrated. Blood-vessels have 
never been found in cartilages, ligaments, the epithelial tissues, 
and the epidermis. We may as well declare them inanimate for 
similar reasons. Moreover, the fact that direct means of com- 
munication between the mother's organism and the fecundated 
ovum, prior to the formation of the placenta, have not been dis- 
covered, is not to be received as proof of their non-existence. 
Reasoning by analogy, we know that the means of preserving life 
therein are not lacking. 

The fertilized human ovum is not like the seed that has been 
wrapped in an old mummy, and left for centuries to await the con- 
ditions for its development. Its growth is steady and constant, 
progressive, physiological and positive. The qualities it has 



THE DISEASES OF PBEGNAKCY. 333 

derived from either parent are preserved. The predominant 
traits of temperament and predisposition, the idiosyncrasies and 
individualities that go to make up the separate being in subse- 
quent life, are there in esse. The hereditary features, and physi- 
cal bias, the mental capacity and character, which are latent and 
undiscoverable to us, are nevertheless epitomized in the develop- 
ing germ. If, prior to quickening, the mass were inanimate 
or dead, this could not be true ; nor would it be possible, when 
two or three months had elapsed, for the mother, however imagi- 
native, to imprint such paternal characteristics as are frequently 
inherited upon her offspring. The very fact that these peculiari- 
ties are perpetuated is proof positive of constant development 
and physiological change. 

Quickening is not a reliable criterion of the vitality of the 

embryo, for the obvious reasons that it does not begin at a fixed 

and determinate period of pregnancy ; that 

i Qu if h ? fe ing not the first ^ * s fr eo L uen tly lacking throughout gesta- 
tion ; that it may be confounded with ab- 
normal sensations of various kinds ; and that the force of the 
impulse felt by the mother may be very strong in case of a 
weakly infant, or vice versa. It is more than possible that foetal 
movements may occur for some weeks before they are recognized 
by the mother. Auscultation of the abdomen discloses the ex- 
istence of these movements before the pulsations of the foetal 
heart, or even the placental souffle can be heard. Not long since, 
a mother told me that, after its birth, a foetus of a little more 
than two months kicked quite violently ; and at a very early 
period of gestation they have been known to breathe and cry 
when suddenly expelled the uterus. 

From my frequent allusion to abortion as an indirect cause of 
many of the diseases of women, you already have an idea of the 
importance cf this subject. For the whole 
di^as°e rtIon as a ° ause ° f °L Uest i 011 °f its prophylaxis, the right, and 
wrong, and responsibility of it, must be set- 
tled by medical men. Nothing could be more natural than for 
a sudden and forcible interruption of the textural changes and 
sympathetic relations, peculiar to pregnancy, to result in more or 
less of disease and disorder. The ovaries, the mammary glands, 
the uterine walls, vessels and lining membrane, and the nutritive 



334 THE DISEASES OF WOMEN. 

and nervous systems are especially apt to suffer ; and, strange to 
say, with certain exceptions, the earlier the period of the abor- 
tion, the greater the liability to these unfortunate sequelae. 

The list of these contingent and consecutive ailments is a long 

one. It includes the different forms of ovarian inflammation, 

ovarian dropsy, every species of menstrual disor- 

Sequelae of abortion. . . , . 

der, peri- and para-metritis, metro-peritonitis, 
hematocele, the formation of moles, hydatids, fibroids, and uterine 
polypi, uterine displacements, uterine and vaginal flstulae, subse- 
quent abortion, atresia of the cervix uteri, sterility, hysteria, dys- 
pepsia, neuralgia, leucorrhcea ; malignant diseases, as cancer, at 
the climacteric, and mania. 

Such an array of the possible consequences of abortion, whether 
accidental or induced, should lead you to make an especial effort 
to prevent it, whenever it is possible. I have placed upon the 
black-board a table of the causes of abortion, which you would 
do well to copy into your note-books, and study at your leisure : 

I.— Constitutional or Predisposing. III. — Reflex, or Exciting. 

t -Plethora, I.— Centric : 

-Anamia and Chlorosis, Emotional, as Fright, Anger, Grief, 

— The Scrofulous Diathesis, etc -> 

—The Menstrual Molimen, Direct blows upon the head or back, 

—Zymotic Diseases : Cerebro-spinal meningitis, 



Syphilis Cerebro-spinal effusion, 

Mercurialization, ■ Hysteria and Epilepsy. 



Variola, 



■Excentric: 



Scarlatina, Parotidean Irritation, 

Diphtheria, Thoracic do. 

Cholera. Mammary do. 

Dental do. 

Gastric do. 

Rectal do. 

II.— Local, or Organic. Vesical and Renal Irritation, 

Vaginal Irritation, 
r.— Malformation of the Ovum. Falls . jumping, blows, etc., 

2 _ " of the Membrane (moles, Functional and Organic Disease of 

hydatids). the Womb, 

3.— Placental Abnormalities : Dltto of the Ovaries, 

Mal-location of, (placenta previa.) Death of the Embryo, 

Organic disease of, Shock from cold injections, cold 

Detachment of, bath > etc - 

Fatty degeneration of, Genital irritation (coitus), 

Calcareous ditto. Do - do - (instrumental). 

IV. — Medicinal. 

This class includes the various emmenagogues, or oxytoxics, which have been known 
to cause the uterus to empty itself of its contents, among which are tansy, (tanacetum 
vulgare). ergot, (secale cornutum), cotton plant (gossypium herb.), quinine, cantharis, 
electricity, and some others. 



THE DISEASES OF PREGNANCY. 335 

You could not have a better illustration of the importance of 
this subject than the history of this case affords. It is more than 
possible that, until my young friend here was called to the rescue, 
no one had an intelligent idea of this poor woman's condition. 
The first doctor who came to her, and who sealed up the flow so 
promptly, should have impressed upon her the absolute necessity 
for rest and quiet. He should have insisted upon her remaining 
in bed, with as much care, and for as long a time as if she had 
just passed through labor at term. If he had taken this precau- 
tion, and given her no medicine whatever, she would probably 
have recovered without any untoward symptoms. 

But he did nothing of the kind, and the consequence was that 

she became very ill, and, worst of all, was subjected in turn to the 

tender mercies of several other incompetent 

in effects of wrong diag- doctors. One said that she had enteritis, 

nosis. 7 

another neuralgia of the liver (!), a third 
hypertrophy of the womb, and a fourth dyspepsia. Their diagno- 
sis was wrong, and hence their treatment could not be right. 
She greAV worse instead of better. 

This brings us to the practical lesson that I wish to draw from 

the case before you. It concerns the difficulty of diagnosticating 

the diseases that may accompany or follow 

Difficulty of recognizing abortion. For I am confident that this pa- 

the sequelae of abortion. Jr 

tient's experience at the hands of her physi- 
cians is by no means an uncommon one. In truth it is very dif- 
ficult, and sometimes quite impossible, to decide whether this or 
that class of symptoms of which women complain is or is not re- 
ferable to abortion as a cause. The perplexity is increased by our 
liability to confound it with delayed or painful menstruation, 
menorrhagia, membranous dysmenorrhea, and by the possibility 
that the patient, if so disposed, may deceive us, by leading us to 
believe that she has miscarried when she has not, or vice versa. 
Add to this that in many cases the diseases of the womb and of 
the ovaries which follow abortion run a latent course ; or they 
may partake of just enough of the hysterical "mimicry " to counter- 
feit other diseases, as for example peritonitis, enteritis, cystitis, etc. 
A recent writer* has published the following table upon the 

* Dr. Van de Warker, in the Journal of the Gynaecological Society of Boston, vol. 
IV, pp. 297-8. 



336 



THE DISEASES OF WOMEN. 



differential diagnosis between spontaneous and induced abor- 
tion : — 



Accidental and Spontaneous Abor- 
tion, to the Third Month. 

1. Ovular abortion may occur and simulate 
dysmenorrhcea. Later ; a gradual cli- 
max of symptoms, thus : loss of appe- 
tite, depression of spirits, pain in the 
loins, weight at anus or vulva, pain in 
breasts, followed by haemorrhage and 
expulsive pains in the uterus. 

2. From accident ; sharp pain in the back, 
loins, or abdomen ; often an interval 
of a day or two, or more, and then 
pains renewed violently and bleeding. 

3 Evidence of history ; habitual abor- 
tion, previous ill-health, or plethoric 
state. 

4. Often a history of uterine displace- 
ment. 

5 As a rule the pulse rarely reaches 
100. 

6. As a rule, there are no symptoms of 
inflammatory complications of the 
uterus or the abdominal viscera. 



Instrumental Abortion, to the 
Third Month. 

:. Marked constitutional disturbance from 
the first. Rigors, fainting or collapse, 
severe pain in the hypogastrium, often 
extending over the entire abdomen, 
and marked tenderness on pressure. 



2. Expulsive pains before the haemorrhage 
Pain severe in the back, and in a line 
from the umbilicus to the sacrum, pain 
and haemorrhage occurring together. 
Large clots. 

3. Evidence of history. Previous good 
health. Evidence of habitual abortion 
absent, or doubtful. 



5. As a rule pulse from 100 to 120. 



As a rule there are always symptoms 
of inflammatory complications, and 
tenderness on pressure over the uterus. 
Os and cervix enlarged and extremely 
tender to the touch. 



Treatment. — In case of threatened abortion, it will become your 
duty, whenever possible, to prevent it. If, however, delivery is 
inevitable, you must conduct it to a safe termination for the moth- 
er. But your interest in the case will not end with the expulsion 
of the embryo, or the birth of the foetus, as the case may be, any 
more than the surgeon's interest in his patient should end with 
the operation of cutting off a leg, or stitching up a wound. Suc- 
cess may depend wholly upon the after-treatment. 

First, then, as in surgical fever following bodily injuries and 
surgical operations, rest is the great remedy. A woman, the lin- 
ing membrane of whose womb has been forcibly 
torn off in an early abortion, perhaps, by the 
use and abuse of instruments, or whose placenta has been pre- 
maturely detached in miscarriage, is as unfit for exercise as the 
man who has but just undergone an amputation of the thigh. Un- 
der these circumstances it is as necessary and proper that the ute- 
rus should repose quietly as that the stump should not be injured 
by the patient's hobbling around. 



Rest. 



THE DISEASES OF PREGNANCY. 337 

I know there are women who ignore and disregard these pre- 
cautions, and who do really escape any very serious consequences. 
But, depend upon it, these cases are exceptional. Thousands of 
them suffer and die of obscure, or more obvious, uterine disease as 
the result of a lack of care after a miscarriage. It is no uncom- 
mon thing for women to leave home on a long journey directly 
after "getting through," or even while they are in danger of 
aborting on the way. And some of you know from experience 
what it is to have such patients come to you from a neighboring 
town or city directly after an " operation," looking to the murder 
of the little innocent, has been performed. In this case the un- 
known city doctor kills -the offspring, while, despite your best 
efforts, the ride and the excitement may cost the mother her life. 
The analogy between the post-partum effects of abortion and 
the sequelae of a severe injury, or surgical operation, suggests the 
use of arnica both locally and internally in these 
cases. The strong tincture may be diluted in the 
proportion of one part of the arnica to six of water, and applied by 
means of compresses over the hypogastrium and pudenda. If the 
patient flows freely, or is particularly addicted to haemorrhage, the 
water should be cold ; otherwise, if she prefers, it may be tepid 
or even warm. You can advise whatever attenuation of arnica you 
choose, to be taken internally at the same time. 

A very common, and a very useful prescription, of the stereo- 
type sort, is to give aconite and arnica in hourly or less frequent 
alternation. These remedies are wonderfully 

Arnica with aconite. . . . . 

efficacious in warding oft the incidental lever 
and traumatic inflammation. This prescription may serve you a 
good turn in case you find it impossible to visit such patients very 
often or regularly. It should be given as soon as the delivery 
and its immediate dangers are passed. Aconite is particularly in- 
dicated if the miscarriage was caused by fright, and has been 
followed by fear and dread of fatal consequences. 

In case of the development of quasi-inflammatory symptoms, 
as in the spurious peritonitis, of which I have already spoken, 

ovarian irritation or neuralgia, undue determi- 

Belladonna. . 

nation of blood to the pelvic viscera without 
haemorrhage, excessive perturbation, unrest, and nervous irritabil- 

22 



338 THE DISEASES OF WOMEN. 

ity, with more or less acute pain, local or general, I know of no 
remedy so useful as belladonna. Atropine in the third decimal 
trituration will somtimes remove these symptoms like a charm. 

Chamomilla, colocynth, ignatia, hyoscyamus, and other poly- 
chrests will be useful under appropriate indications. If the pains 
assume the character of genuine after-pains, camphora, caulophyl- 
lin, belladonna, or nux vomica, may be required. If real metri- 
tis, phlebitis, or cellulitis shall result, the case will become more 
serious, and you will need to study very closely in order to find 
the appropriate remedy or remedies. Do not forget to give due 
weight to the accidental, as well as to the emotional causes of 
these secondary disorders. But I need not repeat what I have 
already said concerning their treatment. 

If the abdomen is tympanitic, and exceedingly tender to the 

touch, order the dry, hot, bran poultice, or the application of dry 

heat by means of plates wrapped in flannels, 

Local treatment. 1 . ' _ 

or have the abdomen covered with cotton bat- 
ting, or hot flannel. If the pain is circumscribed, and limited to 
one or the other ovarian region, it is possible that relief may follow 
a change of posture. Have the patient " change sides," and learn 
if she cannot lie with more ease upon one than upon the other. 
Forbid cold drinks while she is suffering, and let all her clothing, 
and that of the bed, be warm and dry. The chamber should be 
well ventilated, but do not allow a draft of air to pass near or over 
the bed. Place the patient in the most favorable position for re- 
gaining her health. And, what is sometimes as important as 
anything beside, see to it that officious neighbors and nurses, (and 
doctors too,) do not swarm about your patient in your absence. 
This woman is practically cured, and I will not change the pre- 
scription ; for it is a good rule in medicine as well as in morals to 
"let well enough alone." 



LECTURE XXI . 

STOMATITIS MATERNA: NURSING SORE MOUTH. 

Nursing sore-mouth; its Nature, Peculiarities, Symptoms, Diagnosis, Prognosis, and 
Treatment. 

This is one of the most interesting, as well as vexatious diseases 
with which we are acquainted. It is interesting because of its 
limited history and prevalence, its peculiar pathology, its mor- 
tality under the old regime, and the imperfect development of its 
therapeutics ; vexatious, because of its multiplied forms and com- 
plications, and its intractable nature, if not modified and remedied 
by appropriate means. 

Nature. — Concerning the essential nature of this malady, vari- 
ous opinions have been, and are still, entertained by the profession 
at large. The 'most plausible of these, we 

Theories of its origin. 

apprehend, is that which refers its phenomena 
to a scorbutic cachexia. It has been convenient for the majority of 
medical men to attribute its origin to miasmatic influences ; to a 
diminution of the red corpuscles of the blood ; to scrofula ; to 
menstrual irregularities, antecedent to conception ; to a depraved 
and insufficient nourishment, and the like ; but the best writers 
incline to the opinion that this catalogue embraces only the crude 
outline of its causes and consequences, while it leaves the radical 
nature of the malady itself an open question. 

That it is of scorbutic origin is evident, from the following con- 
siderations : 

First ; its causes are such as tend to derangements of nutrition 
and assimilation. 

Second ; it is invariably accompanied by anaemia. 

Third ; except in degree of violence, many of its symptoms are 
identical with those of the scurvy. 

Fourth ; the same dietetic regulations are requisite to cure the 
one as the other. Both demand a pabulum largely composed of 
vegetables, and of vegetable acids especially. 



340 THE DISEASES OF WOMEN. 

Fifth ; they are alike mortal under treatment by excessive and 
improper medication, as by mercurials, quinine, etc. ; and this 
fatality is induced by an identical process of disintegration of the 
tissues, in which their elements are forced to remain, without 
elimination, as abnormal constituents of the blood. 

Sixth , those remedies which are most valuable in stomatitis 
materna, are also such as are most successfully employed against 
scorbutus. 

Peculiarities. — The stomatitis materna has the following 
characteristics: It is peculiar to females, and always to women 
during the term of utero-gestation, or at some 
iaaL?ion d t0 gestation and period of lactation. A few writers, indeed, claim 
to have witnessed examples of this disease in 
males ; but as a rule, one would as readily anticipate attacks of 
"morning sickness," among the latter sex (rare cases of which do 
indeed occur), as of this particular variety of stomatitis ; and in 
what follows, we are therefore to declare, and to keep in view 
the essential characteristics aforenamed. 

Symptoms. — These may be properly classed into local and 
general. 

The local symptoms of the stomatitis materna are not subject 
to a regular order of development, but vary with each particular 
example of the disease. Their more usual 
approach, however, is as follows : The patient 
calls attention to a burning or scalding sensation in the mouth, 
which sensation is greatly aggravated by the taking of warm, 
or even of cold drinks, and by efforts to masticate her food. 
Upon inspection, the physician remarks a fiery, red appear- 
ance of the mouth, which redness is found to exist in patches, or 
diffused more or less continuously over the whole buccal surface. 
Sometimes this eruption is isolated, presenting the appearance of 
ulcerated tubercula of the size of a pea, more or less. Again the 
aforesaid patches attain the diameter of a quarter of a doilar, 
when they may degenerate into ragged and indolent ulcers, thus 
constituting the worst examples of the disease which are to be 
met with, and which frequently spring from chronic neglect, or 
from that still more deplorable cause — a dyscrasia induced by 
drugs that have been ignorantly prescribed for their removal. 

With this local inflammation, whether it be diffused or isolated, 



THE DISEASES OF PREGNANCY. 341 

deep-seated or superficial, there are other symptoms which are 
equally characteristic. Among these there will 

Incidental symptoms. in'i -11 -n Pvi o 

be round a marked pallor 01 the s-uriace, 
resembling chlorosis ; a sad and dejected expression of the coun- 
tenance ; soft, flabby muscles, while the rotundity of the form 
remains as in health ; anorexia, pyrosis, and other disorders of 
digestion ; a profuse flow of saliva ; the tongue is red and smooth ; 
cutting and colicky pains from the simplest ingesta ; alternations 
of constipation and diarrhoea ; strangury, with strong and scalding 
urine, which is acid to test paper ; palpitation, especially trouble- 
some at night ; the secretions are generally normal, the skin soft, 
but without any sensible perspiration ; and, if during lactation, a 
decided sympathy between the child and its parent, whereby it is 
discovered to have inherited thus early, some of her more imme- 
diate and palpable frailties. 

Chronic cases are likely to be accompanied by a diarrhoea which 
is chargeable to an extension of the specific inflammation to the 
middle and inferior portions of the alimentary mucous membrane. 
This symptom is frequently a very perplexing one, as well on 
account of the increased emaciation and debility which it occa- 
sions in every case, as because of its intractable nature, as 
shown in its alternating with the mouth symptoms, being better 
when they are worse, and vice versa. 

In these examples, it is not unusual to discover that all the 
mucous membranes lining the different interior surfaces of the 
body partake of this inflammation. Thus the inner coats of the 
larynx, the trachea, and of the lungs, of the pharynx, oesophagus, 
and of the whole alimentary tract, as well as of the vagina and 
urethra, are sometimes found to be separately or universally 
involved. Hence result great disturbances of function, nutrition, 
etc. ; for the destruction of the epithelial scales which marks the 
invasion of this disease upon local surfaces, interferes very 
materially with the healthy condition and requirements of those 
organs which are indirectly but more seriously implicated. 

The foregoing symptoms are liable to so frequent modification, 
both in the order of their succession and in their severity, that 
authors have fancifully described some three to five distinct varie- 
ties of the nursing sore-mouth, for which classification, practically 
speaking, there would appear to be no real necessity. We shall, 
however, consider a few of them separately. 



342 THE DISEASES OF WOMEN. 

Of the buccal symptoms : These are the primary and more 

palpable symptoms of the stomatitis materna. There is very 

little question, however, but that these local 

A constitutional disease. 

phenomena are symptomatic of a more pro- 
found disturbance of the general organism ; and that, properly 
speaking, we are to regard them as the certain evidence of some 
such original disorder. Examples are not wanting in which this 
disease is believed to have pursued a latent course in the system, 
during which interval, for a greater or less period of time prior to 
the development of these symptoms, it has sapped the strength 
and impaired the functional processes of the economy. 

Indeed there is every reason to believe that those cases of 
digestive and assimilative disorder, incident to utero-gestation, 
which distress and harass the patient exceedingly while carrying 
the foetus, and which, subsequent to her confinement, will not 
unfrequently result in a manifestation of the above local symp- 
toms, are to be referred solely to the existence of a latent stoma- 
titis from the beginning. These examples are perhaps as infre- 
quent as they are invincible, but in the practical experience of 
those physicians whose opinions are of value, the remark will 
hold good that it is only through a close and careful study that 
we may come to appreciate the worth of this class of symptoms, 
as affording us an index at once to their pathology and treatment. 

The peculiar characters which such symptoms present are found 
to vary with the severity and duration of the complaint. In very 
mild cases the eruption assumes more of an erythematous appear- 
ance, being diffused in patches over the sides of the tongue and 
of the cheeks. Or it may consist of common vesicles, resembling 
the aphthae adultorum of some writers, which vesicles ultimately 
degenerate into more or less troublesome centers of infection, 
each showing at its base a hardened and whitish colored ring. 
These indurations terminate either by cicatrization or ulceration. 
To this form of the complaint the name of follicular stomatitis 
has been given, for the reason that the peculiar eruption finds its 
more frequent seat in the mucous follicles of the mouth. 

In bad cases, when these vesicles burst, they develop into ulcers, 

which are either superficial or deep-seated. If the system has been 

very much depraved, and the vitality runs low* 

The local ulceration. , ., , -■ r 

these ulcers may be very numerous and ot 
large size. You will find them located on the sides or upon the 



THE DISEASES OF PREGNANCY. 343 

upper surface of the tongue, upon its fraenum, on the fraenum of 
the lower lip, on the gums, the cheeks, or the roof of the mouth, 
and even in the throat and fauces. They are painful in propor- 
tion to the extent of the raw surface which is exposed, and to the 
depth of the ulceration. In exceptional instances the,;e ulcera- 
tions have dipped down to the bone beneath. 

It is not unusual for these characteristic lesions to disappeaz 
suddenly, leaving the patient in apparent health. After a brief 

interval, however, they reappear, and may thus 
lesion rcious nature ° f the keep coming and going for weeks, or even for 

months. In the most serious cases this sudden 
metastasis increases the danger, by implicating other and more 
vital organs. 

Symptoms of gastric or alimentary disorder almost always 
accompany those peculiar to this variety of sore-mouth. They 

may precede, follow or alternate with the buccal 

Incidental gastric disorder. 

symptoms, but are rarely altogether absent. I 
have seldom treated a case of this form of stomatitis, during 
either pregnancy or lactation, which was not accompanied by- 
epigastric uneasiness, anorexia, or pyrosis. Instances in which 
this disease runs its course without a more or less decided 
implication of the stomach and bowels are believed to be very 
rare. 

In this respect the stomatitis materna resembles the aphthae of 
infants which, as you are aware, is almost invariably accom- 
panied by intestinal derangement, more especially indigestion 
and diarrhoea. 

The concurrent digestive disorder in this variety of sore-mouth 
has been attributed to various causes, among which are the imper- 
fect mastication of food ; an improper and 
dera a n u geme°nt. the digestive unwholesome diet ; the actual transfer, or the 
continuation, of the local lesion to the gastric 
•and enteric mucous membrane ; to a depraved nutrition from other 
causes, and to glandular disease either in the intestine or the 
mesentery, or both. 

Among the numerous contingencies of pregnancy and parturi- 
. . , tion there are few which are more troublesome 

Diarrhoea. 

than an inveterate diarrhoea. This is especially 
true in patients of a scrofulous or tuberculous diathesis. And it 



344 THE DISEASES OF WOMEN. 

is this class of subjects which is most liable to be seized with it 
after labor. When complicated with stomatitis the diarrhoea may 
either anticipate or follow the symptoms already enumerated. 
More frequently, however, it alternates with them — a fact which 
implies a metastasis of the peculiar disorder from the oral to the 
intestinal mucous membrane. 

Disordered digestion and assimilation are, therefore, almost cer- 
tain to exist in well-marked cases of stomatitis materna. Not 
unfrequently they are the source of well-grounded apprehension, 
and, if ever so slight, they will occasion you no little anxiety. 
You should bear in mind, however, that the coincident diarrhoea 
is but a symptom, and that its essential pathology is the same as 
that of the buccal erythema, eruption, and ulceration. 

Beside local suffering in the mouth, the patient may complain 
also of a troublesome strangury, with smarting or scalding sensa- 
tions during, or immediately after urinating. 
toSs nal and vesical symp " Occasionally these symptoms precede those 
already enumerated. Sooner or later they are 
almost certain to be present, and when they are not mentioned 
voluntarily, you will learn, upon inquiry, that they really exist. 

The urine is most commonly acid in its reaction — a symptom 
reputed by some authorities to be pathognomonic of this variety 
of stomatitis. Its specific gravity will vary from 1024 to 1030. 

For the most part, the general symptoms are such as imply a 
debility which may be extreme. If the disease has existed for any 
considerable time, the patient is usually anaemic. 
She is pallid and exhausted, and the face ap- 
pears puffy and bloated. Her complexion is less waxy and clear 
than in chlorosis, but has a sallow and cadaverous shade in it, 
which is not common in other diseases. 

These symptoms are likely to be accompanied by an irritative 
fever which may remit regularly and finally develop into a real 
nectic. It is said that primiparae are more liable than multiparae 
to this form of stomatitis. With certain women it appears to be 
constitutional, and always recurs during pregnancy or lying-in. 
irie milk furnished by the breast may be either deficient or ex- 
cessive in quantity. Not unfrequently it is of such quality as to 
poison the child and render it sickly and short-lived. 

Wherever it may be located, authorities are not agreed as to 



THE DISEASES OF PREGNANCY. 345 

whether the anaemia in this disease is the cause or the conse- 
quence of the local inflammation and ulcera- 
tion. The simple fact that it is limited to the 
periods of gestation and lactation, when the blood is being drained 
of certain elements for the support of the young, and that, as a 
rule, it ceases as soon as the child is born, or weaned, suggests 
that the anaemia must have preceded the local lesion. And such 
is the case. The woman may have been in ill-health for a con- 
siderable time before the sore mouth commenced. This primary 
impairment of the quality of the blood explains the greater lia- 
bility of young, scrofulous, weakly and sickly persons, as well as 
of those whose systems have been reduced by frequent child- 
bearing, to the disease under consideration. It also affords a 
reason for the more general prevalence and malignity of this dis- 
ease in miasmatic districts, and in those localities and seasons in 
which there is a scarcity of fruits and vegetables, and where, as a 
•consequence, the stomatitis degenerates into a species of " land 
scurvy.*' 

We can not otherwise explain the migratory character of the 
disease, its tendency to invade the pharynx, the oesophagus, and 
the gastro-intestinal tract, the respiratory apparatus, the nasal 
passage, the Eustachian tube, and even the genito-urinary outlet. 
In the order of its occurrence therefore, the anaemia is doubtless 
the first visible sign of the impaired nutrition upon which the 
stomatitis really depends, and without which it can not exist. 

This form of stomatitis may commence in the early, the middle, 

or the latter months of gestation, and persist to term or even later. 

Or it may date from delivery, from the first 

Onset of the disease. 

month oi nursing, or perhaps later and continue 
for an indefinite period. In very rare cases it exists in the form 
of pruritus of the vulva during pregnancy, and after child-birth 
develops into stomatitis proper. 

Diagnosis. — The diagnosis is not difficult. The sex of the 
subject and the peculiar circumstances in which she is found — 
either pregnant, or in one or another of the stages of recovery 
from her confinement,— with the local symptoms already detailed, 

will enable you to diagnosticate it readily. It 

It may be latent. . 

is only when this disease is obscure and runs a 
latent course, being limited to the gastric, alimentary, or urinary 



346 THE DISEASES OF WOMEN. 

mucous membranes, that you would be likely to overlook it, or 
fail to distinguish it from other similar and serious affections. 

Prognosis. — The prognosis will vary with the original strength 

of the patient's constitution ; her age, habits and surroundings; 

the co-existence of tuberculosis of the lungs, or 

Qualifying circumstances. . . 

ot the mesenteric glands; the period ot the 
commencement, and the duration of the disorder ; the type and 
persistence of the accompanying fever ; the seat, nature and ex- 
tent of the local lesion ; the ansemia and the emaciation. 

If, prior to becoming pregnant, the patient was robust and 
healthy, and had no cachexy, either hereditary or acquired, the 
probabilities are in favor of her recovery. This result is the more 
certain if she is young, of good habits, and lives in a healthy 
neighborhood. A tendency to phthisis in any of its forms is 
always a grave complication. If the stomatitis commences in the 
early months of gestation, it can seldom be cured before delivery, 
and other things equal, the longer its duration prior to labor the 
greater the danger. In rare cases it results in abortion, after 
which it ceases spontaneously. 

If the accompanying fever is either typhoid or hectic in its type 
and character, you will need to qualify your prognosis. And so 
also if the disease has become chronic, with deep-seated ulcera- 
tion in the intestines, the stomach, or the larynx and trachea. 
The occurrence of passive, or repeated, or excessive haemorrhage 
from the mucous surface implies great danger. The more the 
blood is impoverished and vitiated, and the greater the emaciation 
and the muscular and nervous exhaustion, the fewer the chances 
of a speedy and certain recovery. It is sometimes quite impos- 
sible to eradicate this disease in the case of women who have had 
it in several successive pregnancies. Although recovery fre- 
quently follows the weaning of the child, yet even this expedient 
sometimes fails. The danger is increased by excessive or pro- 
longed medication. 

Treatment. — The first thing to be clone is to select a suitable 

diet. This consists of a proper admixture of vegetable and 

animal food, for you will observe that in many 

cases the patient has lived almost exclusively 

upon meat. In frontier settlements, people sometimes eat little 

or nothing excepting bread and bacon. In such communities the 



THE DISEASES OF PREGNANCY. 347 

women suffer from an aggravated form of the nursing sore-mouth T 
which is closely allied to scorbutus, and which may sometimes be 
cured by merely regulating the diet. Even in towns and cities 
similar cases are not infrequent. 

The taking of solids is usually so painful that food must be 
given either in the semi-solid or fluid form. If, however, she can 
eat it, rare roast beef or mutton, or broiled meats which are juicy 
and nutritious, may be prescribed with good effect. She may 
also have milk, eggs, oysters, game, plain custards, animal jellies, 
cracked wheat, oatmeal, or, if she prefers,' a little codfish with 
cream. Salt food may be permitted as an appetizer, but should 
be used sparingly. Potatoes, carrots, tomatoes, baked apples, 
and other fruits and vegetables, if fresh and fully ripe, are not 
only permissible but indispensable. Cures have been effected by 
allowing the patient to drink freely of butter-milk. 

Other acidulated drinks are almost specific. Lemonade, orange- 
ade, and jelly -water, are most available. They may be taken 
either warm or cold, as the patient prefers, and 

Acidulated drinks. . 

are not contra-indicated m most cases of indi- 
gestion and diarrhoea. Nor will they antidote the proper reme- 
dies. The best criterion, in their selection, is to consult 'the 

patient's preference, or craving, if she has any. 

Rule for choosing them. . . ° 

The same is true with respect to the diet. As 
a rule, you may let her have whatever she longs for in the way of 
food or drink, providing it is not wholly indigestible or absolutely 
poisonous. The malt liquors and cod-liver oil have also been 
added to the bill of fare. 

The expedients devised to check this disease, and to hold it in 
abeyance, and which are sometimes successful, 
thfs x d p ise d i e se. ts forarresting are the induction of premature labor, the wean- 
ing of the child, and a change of climate. 
The induction of premature labor is justifiable only in those 
extreme cases of stomatitis in which it is morally certain that the 
patient must die unless pregnancy is terminated 

Premature labor. ± ° J 

and the womb emptied of its contents. Fortu- 
nately such an extremity is almost never reached prior to the 
seventh month of pregnancy, after which the child is viable. In 
a resort to this expedient under such circumstances there is no 
warrant for the performance of criminal abortion, which implies 
and includes the intentional sacrifice of the foetus. 



348 THE DISEASES OF WOMEN. 

Because taking the child from the breast of the mother who 

has stomatitis will sometimes be of immediate and lasting benefit 

,„ . , to her, physicians have inferred that weaning 

Weaning the child. i i 

was the best remedy. The custom with some 
is to prescribe it indiscriminately. So soon as they discover the 
slightest inflammation and exfoliation of the oral mucous mem- 
brane, further nursing is prohibited. But weaning will not always 
mitigate or arrest this disease. Nor is it necessary to resort to 
this expedient in a majority of the cases that come under our care. 
Unless it is manifest that the mother is pretty nearly bankrupt in 
strength and nutritive resource, that she is drawing her life away 
to keep her child alive, that she is so anaemic and emaciated as to 
be totally unfit both on her own and the infant's account to nurse 
it any longer, we prefer not to interrupt this very important func- 
tion. 

A change of climate, especially if the patient leaves a mias- 
matic district, will sometimes cause the symptoms of this disease 
to disappear promptly and permanently. In 

Change of climate. ri r A J £ J 

exceptional cases a removal ot a tew miles only 
will work almost as marked a change in her feelings as it does in 
certain cases of asthma and of intermittent fever. This expe- 
dient is particularly applicable if the stomatitis is complicated 
with chronic bowel affections. Railway travel is indicated if 
there is an inveterate diarrhoea, and residence in an equable cli- 
mate for those mothers who are consumptive. Hysterical sub- 
jects, with the nursing sore-mouth, may sometimes be sent away 
from home with the greatest relief to themselves and all con- 
cerned. 

The medical treatment of this disorder is constitutional and 
local. Gf internal remedies, the various acids are in the best 

repute. The nitric acid has been given in the 

The medical treatment, 1 . . . , , 

lower and higher potencies, under almost every 
variety of indications, and often empirically, with good results. 
The sulphuric and muriatic acids are equally useful. I remember 
a case in which two prominent physicians had treated a lady for 
stomatitis materna for two whole months. She 
grew worse and worse. Finally they told her 
that she must wean her infant, and that after doing so she could 
not recover her health under at least one year. I made her but 



THE DISEASES OF PREGNANCY. 349 

three visits, ordered a nutritious diet, and prescribed sulphuric 
acid in the third decimal dilution to be taken 
four times daily. She continued the remedy 
for the space of a fortnight. A radical cure followed, without 
weaning the child, or the employment of any local application 
whatever. My practice is to put twenty-five drops of the second 
or third attenuation of either of these acids in half a glass of 
water, of which two teaspoonfuls are to be taken once in from 
three to six hours. 

Arsenicum is generally suitable for cases of this form of stoma- 
titis which are to be met with in malarious districts. If there is 
burning in the mouth, with frequent desire for 

Arsenicum album. -i-i-ii • r> i i • 1 i 

cold drinks ; 11 the water which the patient 
drinks habitually is stagnant or impregnated with decomposing 
matter of various kinds ; if there is great prostration of strength, 
anorexia, with chronic disorder of digestion and painless diarrhoea ; 
if the system has been poisoned with quinine in large doses, or if 
the accorapairying symptoms are analogous to those of typhoid 
fever, it may prove of excellent service. The same indications 
will call for natrum muriaticum. Dr. Murch was in the habit in 
these cases of alternating the arsenicum with small doses of Bel- 
locq's charcoal. If the disease is complicated with glandular dis- 
ease of a scrofulous or syphilitic character, the arsenicum jodatum 
might be preferable. Dr. D. T. Brown* has witnessed the best 
effects from preceding the employment of arsenicum with a few 
doses of carbo vegetabilis. Dr. W, C. Barker extols the use of 
" arsenicum 6th in alternation with sulphur 6th, repeated once in 
four hours, in those cases of nursing sore-mouth which are char- 
acterized by a very slight and almost imperceptible odor of the 
breath, with considerable prostration of the general strength." 
Dr. I. S. P. Lord vouches for the superior efficacy of arsenicum 
and natrum muriaticum in the 30th, in preference to other attenu- 
ations. 

The form of this disease to which mercurius is best adapted is 
that in which the ulceration of the tissues is very marked. The 

ulcers are corroding, the breath offensive, the 

Mercurius. ° 7 

secretion of saliva profuse, in short, the symp- 
toms are those of the stomatitis ulcerosa of the old writers. If 

* Vide Transactions of American Institute of Horn., for i860, p. 78. 



350 THE DISEASES OF WOMEN. 

there is no syphilitic taint, the mercurius corrosivus is preferable, 
otherwise the mercurius joclatus, or even the mercurius solubilis, 
may be selected. 

Where disorders of digestion in pregnant or lying-in women 

are due to a latent stomatitis, and particularly in patients who are 

predisposed to scrofula or phthisis, the calcarea 

Calcarea carbonica. . . 

carbonica may be 01 excellent service, I he 
symptoms which indicate it are dryness of the mouth and tongue, 
with a sense of roughness and stinging ; a dry, bitter, sour, or 
metallic taste ; great aversion to boiled food and to meats in par- 
ticular ; inclination to salt diet, or to such indigestible articles as 
pickles, dirt, chalk, slate-pencils, etc. ; nausea, with acid eructa- 
tions ; vomiting of ingesta ; profuse colliquative diarrhoea, with 
undigested stools ; a sudden metastasis of the eruption from the 
mouth to the alimentary mucous membrane ; and acidity of the 
urine, with burning in the urethra during micturition. There are 
some examples of this disease which it would be very difficult, if 
not indeed impossible, to cure without this remedy. 

Dr. Helmuth reports* that ammonium carbonicum cured a case 
of long standing in which there Was great prostration, hollow 

cough, and burning in the tongue — the whole 

Ammonium carb. , n . . -. . /> n n . rl . -. i 

buccal cavity being filled with vesicles and 
ulcerated depressions, and the tongue swollen, stiff, and very sen- 
sitive to cold air and drinks. 

He also cites the case of a young lady cured by the use of 

baryta carbonica, for which remedy the chief 

Baryta carbonica. .,.,. ,-, iij i ij_ 

indication was the absolute and complete 
anorexia. 

" In an emaciated female who had suffered severely from the 
disease, and had been troubled for a long period 

Natrum muriaticum. ' , ... -i 

with ague, natrum munaticum and arsenicum, 
in repeated doses of the 6th attenuation, effected a cure in twenty- 
one days." 

In the report to the American Institute, from which I have 

already quoted, my friend, Dr. N. F. Prentice, says: "Formerly 

I had a great deal of trouble in the treatment 

of this disease, and of sore, mouth in children, 

but during the last three or four years I have used the veronica 

*U. S. Journal of Horn., Vol. I, p. 413- 



THE DISEASES OF PREGNANCY. 351 

(empirically it is true, for I have but a very few provings of it,) 
almost exclusively, and with universal success. I have been in 
the habit of giving it internally in the first decimal attenuation, 
and of applying it locally to the mouth in the proportion of ten 
to thirty drops in two fluid-ounces of soft water. When they are 
indicated, I use other remedies in alternation with veronica." 

Dr. J. Davies has succeeded in some obstinate cases by the 

application of a trituration of the rhus toxicodendron, and an 

internal use of the attenuations of the same 

Rhus toxicodendron. . . _ ' 

remedy. He triturates the berries ot this plant 
with saccharum lactis, in the proportion of one berry to ten grains 
of the sugar, and applies the powder, moistened, through the 
medium of a thin linen cloth. 

Other remedies which are sometimes serviceable are belladonna, 
causticum, china, nux vomica, sulphur, hepar sulphuris, ferrum 
and staphisagria. 

Topical applications of various kinds are grateful and beneficial. 
The most common and harmless consist of lotions, washes and gar- 
gles, composed of borax, or borax and honey, 

The local treatment. 

sage and borax, a mixture 01 equal parts ot 
borax and sugar in a pulverized state, tincture of myrrh, an infu- 
sion of the golden seal, or of cayenne pepper, butternut oil, or 
glycerine. Some physicians recommend the chlorate of potassa 
to be dissolved in glycerine and applied locally. Others prefer a 
very weak solution of the carbolic acid. And yet others are in 
the habit of prescribing the topical use of hydrastin in water, or 
glycerine, or both. In cases where the buccal and faucial mucous 
membrane is badly ulcerated and the breath is fetid and offensive, 
a drachm of the mother tincture of baptisia may be added to four 
fluid-ounces of water and applied locally. Or Bretonneau's mixt- 
ure of one part of hydrochloric acid and three parts of honey may 
be used instead. Dr. Barker has the greatest confidence in fre- 
quent rinsings of the mouth with simple cold water. There are 
those who, in exceptional cases, think it necessary to touch the 
ulcers with a pencil of the nitrate of silver. I prefer calendula, 
or hydrastin. Tannin and other astringents are harsh and revul- 
sive, and may do more harm than good. 

All of these therapeutical resources, however, are of secondary 
importance compared with the good effects of an appropriate diet, 



352 THE DISEASES OF WOMEN. 

a good climate, the stoppage of any nutritive drain, and the cura- 
tive influence of fresh air and the sunlight. No remedy in any 
attenuation, and no local means of any kind will be likely to suc- 
ceed if the general conditions are not supplied ; and therefore our 
first duty, even before choosing the remedy, is to see that they are 
furnished. In the milder cases they are all that is necessary, and 
we can save our medicines for those who really need them. 

And, let me tell you in this connection, that there is more of 
reputation, as well as of good sense and satisfaction, in curing 
some of our patients by means that are within the reach of every- 
body, than there is in the use of those which are more scientific 
and fanciful. " The best physician is he who knows w r hen to with- 
hold his remedies." 

THE RENAL FUNCTION AND THE GRAVID UTERUS. 

The clinical significance of renal inadequacy, of renal embar- 
rassment and of renal inflammation in a pregnant woman who has 
passed the fifth month is very great. For whatever we may say 
of uterine displacements as a source of mischief, those which 
occur while the organ lies above the brim of the pelvis are often 
beset with the most serious consequences to the mother and the 
child. It is then that the body of the gravid uterus should lie 
obliquely, and whatever forces it into line with the long axis of 
the body, and forces it downward as when primiparse resort to 
tight lacing, will cause the kidneys to be functionally or organic- 
ally diseased through pressure upon the abdominal vessels. Albu- 
minuria, dropsy, a temporary form of Bright' s disease, uraamia, 
puerperal convulsions, mania and paralysis not unfrequently 
result from this cause. 



Part Fifth. 



THE POST-PUERPERAL DISEASES. 



LECTURE XXII. 

SUB-INVOLUTION OF THE UTERUS. 

Sub-involution of the uterus. Case.— Sub-involution with recurrent abortion. Case.— 
Sub-involution and chronic metritis of eighteen years' duration. Case.— Sub-involu- 
tion, chronic metritis, menorrhagia, and prolapsus. Case. 

Under the head of post-puerperal diseases I shall include those 
affections only which, while they do not come under our care dur- 
ing the lying-in period, are yet necessarily related to labor. Being 
a sequence of delivery, whether at term or prematurely, they are 
sometimes styled post-part um affections. Their common and 
cardinal peculiarity is that they depend upon lesions within and 
about the post-gravid uterus, and are therefore limited to those 
who have been pregnant. Such of them, however, as require 
surgical treatment will be considered further on. 

In our obstetrical and puerperal clinics you are being taught at 
the bed-side whatever pertains to the clinical history of labor and of 
child-bed disorders. My own special course on the puerperal 
affections will acquaint you with the most interesting and practical 
part of this very important subject, while it excuses me from their 
consideration in my general course upon the diseases of women. 

Manifestly the list of post-partum lesions should include the 
remote sequelae of abortion, of miscarriage and of premature deliv- 
ery, as well as of labor at term. For a post-abortum laceration 
of the cervix uteri does not differ in any essential particular from 
one that has occurred at the ninth month. Post-partum cellulitis 
and sub-involution of the uterus are the same in both cases, and 
we shall never know how to treat them intelligently until we take 
their common and invariable cause into account. 

21 :*53 



354 THE DISEASES OF WOMEN. 

It is especially incumbent upon us to consider this and kindred 
questions very carefully ; for we, of all others, should discriminate 
between those diseases which are idiopathic and such as are sympto- 
matic, or between the primary and the secondary affections that 
we are expected to cure. When a mother consults us for the 
relief of an intra-pelvie disorder, we should, if possible, satisfy 
ourselves whether the lesion that we find does not date from her 
delivery, no matter how long since her baby was born, or from 
some mishap or neglect which interfered at that time with her 
puerperal convalescence. 

This subject is so very important, and concerns the welfare and 
comfort of so large a class of our patients, that I must beg you to 
give it your especial attention just now, while the opportunities 
for its clinical study are so abundant and so easy of access. 

SUB-INVOLUTION OF THE UTERUS. 

Case. — Mrs. S , aged 37, has not been been well since her 

last confinement, which was six years ago. After the birth of the 
child, the labor being rapid and very painful, but quite natural, 
she Avas taken with uterine haemorrhage, which was very active 
and copious at first, but finally became passive. This haemorrhage 
did not and would not yield to remedies. The doctors could not 
cure it, and it ceased only when she had weaned the child. Sub- 
sequently her menstruation was resumed, but it was too profuse 
and long continued. Sometimes she continues to flow for three 
w r eeks, constantly, and has only one week's interval before the 
period comes around again. But the discharge always lasts a 
fortnight. She has no pain or soreness, but complains of dragging 
sensations in the uterine, ovarian and sacral regions. 

After the third attack of menorrhagia she began to have dropsi- 
cal symptoms. Her face, hands and feet, and finally the whole 
general integument, became puffy and cedematous. Then she had 
palpitation of the heart, and dyspnoea after slight exertion, as in 
walking up stairs. Sometimes she would waken out of sleep with 
impending suffocation, and in order to breathe freely would be 
compelled to jump out of the bed, and to walk about her room. 
This was accompanied by violent beating of the heart, and a sen- 
sation as if she had been struck upon the head. She is positive 
that the urine has always been normal in quantity and quality. 
She has had six physicians, five of whom have treated her for 
" disease of the heart." The other one said she had "ulceration 
of the womb," and applied caustics to the cervix uteri (or there- 
abouts), twice each week, for several consecutive weeks. 



SUB-INVOLUTION OF THE UTERUS. 355 

This bit of clinical history is significant and suggestive. But it 
Is incomplete. The fact that this woman's ill-health dates from 
her last labor, and that the most prominent and urgent symptoms 
relate to the menstrual return, are pretty certain indications that 
something is wronof with the womb. It cannot be ulceration of 
the cervix, merely, for unless it be cancerous such an ulceration is 
never accompanied by so severe a haemorrhage. And if it were 
cancerous it would not have begun so directly after delivery, 
neither would it be apt to return with the regularity of the men- 
strual cycle. 

I have passed the sound into the uterine cavity, and find, by 

actual measurement, that its depth is five inches. The instrument 

entered without difficulty, and passed to the 

The depth of the f undus of the onran without the least obstruc- 

uterus. o 

tion. My first impression on finding the uterine 
cavity of such an increased size, was that its enlargement was 
probably due to the presence either of a sub-mucous, or of an 
interstitial fibroid. But, failing to find any evidence of such a 
tumor, and satisfying myself that the increased development of the 
organ was uniform on all sides, and that its cavity did not contain 
any abnormal growth, I decided the case to be one of subinvo- 
lution of the womb. 

To the " touch" the cervix feels swollen and enlarged; and on 
examination through the abdominal parietes, by conjoined man- 
ipulation, in this manner, an oblong tumor is 

Negative symptoms. ,.-... A ,, , r™ i 

found rising above the pubes. Ihus examined, 
between the two hands, the mobility of the tumor is consentane- 
ous with that of the womb. AVe exclude the possibility of a sub- 
peritoneal fibroid in this case, for the simple reason that, in chronic 
cases especially, extra-uterine growths are not necessarily, and, 
indeed, are almost never, accompanied by menorrhagia. Nor does 
the commencement of their growth date so directly and positively 
from the lying-in. 

• Etiology. — Defective puerperal involution and resorption of the 
womb is more common than is generally supposed, and as a cause 

„ of ill-health is therefore very likely to be over- 

Various causes. -ii-i-r^ „ .- 

looked. It often follows abortion, more especi- 
ally when it occurs after the fifth month. In women of lax fibre 
it is sometimes caused by a too early " getting up " after delivery 



356 THE DISEASES OF WOMEN. 

at term. Those mothers who do not nurse their children at 
first are very subject to it, although in a limited and circumscribed 
form. It is sometimes a sequel of twin-delivery, and also of an ex- 
cessive accumulation of the amniotic fluid. Rapid labors, especially 
if they are not followed by after-pains, are more likely to be fol- 
lowed by defective involution of the uterus than those which are 
tardy and difficult ; and I have remarked the same sequel from the 
use of chloroform in labor. 

The latest generalization in gynaecology ascribes almost every 
case of sub-involution to a laceration of the cervix during or in 
consequence of labor. I shall refer to this subject when I come 
to speak of cervical lacerations and their surgical treatment. In 
the present connection it must suffice to say that, in my judgment, 
Dr. Emmets' view is too sweeping and exclusive. 

This interruption is what physiologists style the " retrogressive 
metamorphosis" of the uterine tissues after delivery, and is intimate- 
ly associated with the clinical history of uterine 
displacements. We cannot reasonably suppose 
that the extraordinary growth of these tissues, which has been 
ofoino: on for months, will be resolved awav and removed in a few 
days after the womb has been emptied of its contents. The re- 
trogressive changes are not always so rapid, and more time may 
be required for the organ to resume its proper size, weight, form, 
and relations. Hence the necessity for post-partum rest in the 
horizontal posture, and for the avoidance of all such causes as 
might derange this very delicate and wonderful process. 

Haemorrhage after delivery bears so important a relation to the 

contraction ot the womb that its occurrence and persistence in this 

case leads us to suppose that, following the 

Hgemorrhage etc, , ^ J . i , • » ,, . . ' 

labor, the involution ot this organ was incom- 
plete. And the uterine tissues must have remained in this relaxed 
state. The subsequent development of menorrhagia, with too 
frequent as well as too copious menstruation, confirms this view. 
So also do the dragging sensations, which she has experienced so 
constantly in the intra-pelvic and sacral regions, and the abnormal 
depth of the uterus 

But how shall we explain the cardiac complication, and why did 
it follow the third instead of the first attack of menorrhagia? 
Manifestly, because of the excessive and continued loss of blood, 



SUB-INVOLUTION OF THE UTERUS. ?57 

-or of the anaemia which resulted from the haemorrhage. If the 
heart symptoms had been dependent upon organic change, they 
would probably have disclosed themselves at an earlier period in 
the history of the case. In real cardiac disease we do not require 
to bleed the patient for diagnostic purposes. Functional derange- 
ment of the heart's action is a frequent accompaniment and conse- 
quence of anaemia and chlorosis, of an impoverished condition of the 
blood from whatever cause, and of chronic uterine and ovarian 
diseases which implicate the nervous system especially. Aud 
although the long-continued operation of these general and local 
causes may finally set up a real organic disease of the heart, yet 
such a result does not always lollow. I have made a careful phy- 
sical examination of this woman's heart, but failed to rind any 
evidence of a structural lesion. And we may reasonably infer that, 
if she has nothing of the kind now. after having been treated for 
" disease of the heart" by rive doctors in succession, she will prob- 
ably be exempt from it in the future. 

Treatment. — I am glad of the opportunity to show you this 

•case, for it is a typical one, and its treatment involves certain 

questions which cannot be regarded as settled. 

Practical dedu:tions. , , . . . , ^ _ 

h\ the first place, this kind ot post-puerperal 
lesion underlies so many other uterine affections, that in many 
cases it is impossible to explain their nature or to treat them in- 
telligently, without reference to what Simpson very properly 
styled a sub-involution of the uterus. And secondly, a practical 
application of our knowledge ol the relation of certain remedies to 
this particular lesion would not only enable us the more promptly 
to cure the original disease, but likewise also, whatever might 
=come of it, or be complicated with it. 

Here the defective involution of the uterus is the prime cause 
of ili-health. That cause is still at work. Manifestly, the first 

indication is, if possible to remove it. But how 

The prime indication. f , 

shall it be done.-' Is there any known remedy 
for this relaxation of the uterine muscular fibre? There are well- 
known remedies which affect this organ, just as there are those 
which decidedly and certainly allect other hollow muscular organs, 
as, for instance, the heart, the stomach and the bladder. These 
include secale cor., sabina, china, and ipecacuanha. 

Ergotism in women is always accompanied by a determination 



358 THE DISEASES OF WOMEN. 

of blood to the internal generative organs, and if the uterine 
muscular fibre is at all developed, as during 
ac^o7ergo°t giCal pregnancy, labor, or lying-in, by expulsive con- 
tractions of the womb. Under the latter condi- 
tions, ergot excites the peristaltic movements of that organ with 
the same certainty that opium congests the brain, and that verat- 
rum viride lessens the force and frequency of the pulse. Its power 
to facilitate delivery at term, and to arrest post-partum haemor- 
rhage is established. This power depends upon an intimate 
physiological relation or affinity between the fully developed 
muscular fibre of the uterus and the spurred rye. 

But you should remember that the similarity of the womb with 
the other hollow viscera is exceptional, and by no means constant. 
Within the limits of health there is no condition in which the 
muscular coat of the heart, the stomach, or the bladder is wanting. 
Yet in the non-gravid uterus, and more especially in those who 
have never been pregnant, this coat has no real, but only a rudi- 
mentary existence; and in those women who have conceived, and 
even carried their children to term, the normal involution of the 
oro-an after labor has restored it as nearly as possible to its ante- 
muscular state. 

So, therefore, we say, that there is a period in the history of 
most women, which is characterized by an extraordinary evolution of 
the uterine muscular fibre, and that the various disease-producing 
contingencies which beset its orowth and decline have their thera- 
peutical counterpart in remedies of which secale is the type. 

The ero-ot is believed to act both through the nervous and the 
vascular systems. It supplies such a variety of motor force to the 
atonic uterine fibre as will stimulate its contraction, and at the 
same time secure a sort of specific or physiological torsion of the 
capillaries. This makes it the remedy for those haemorrhages which 
depend upon a lack of uterine contractility ; and there seems but 
little reason to doubt that if our patient had taken it directly 
after her delivery, the womb would have been closed, the haemor- 
rhage controlled, and the retrogressive metamorphosis of the 
tissues established. But, instead of such a complex and very desira- 
able result, the womb remained flaccid, and did not fold upon 
itself; the blood ceased flowing temporarily, when there was little 
more to lose, but commenced ao-ain with the recurrence of the 



SUB-INVOLUTION OF THE UTERUS. 359 

monthly crisis; and the organ is larger and deeper to-day than it 
should have been an hour after the birth of the child. 

Here, then, is the chief point in this case. The symptoms given 
followed her last confinement, six years ago, and with every men- 
strual return since that time, there being a similar engorgement 
of the uterus, and the same relaxed condition of its walls, she has 
passed through a similar experience. In so far ss the loss of blood 
is concerned, and if it were possible, she might as well have borne 
twelve children each year. And can you see any reason why this 
drain should not impair the quality of her blood, and develop 
dropsical and cardiac symptoms? The only marvel is that she is 
still alive. 

We must treat this defective involution of the uterus, with re- 
current haemorrhage, as we would treat the same train of symp- 
toms, minus the cedema and the dyspncea, if she 

Indications for secale. ... .-; . , . . , ..„ n 

were still m the lying-m chamber. I he first 
indication is to secure the proper uterine contraction. The object 
of this is three-fold viz.: to stop the excessive now, to stimulate 
the absorption of the redundant muscular structure, and to relieve 
her of the pain, and soreness, and dragging sensation to which she 
has been a martyr. This indication is plain and practical. The 
secale cor. may, perhaps, be all the remedy required. I have 
treated several such cases successfully with it alone. My prefer- 
ence is for the second or third dilutions. Sometimes I give one 
and sometimes the other. It is possible, in chronic cases like this, 
that the medium and higher potencies might be as useful ; I cannot 
say. 

Of this one thing, however, you may be assured, that in all such 
cases, whether they are directly or indirectly dependent upon a 
defect, interruption, or irregularity in the organic changes proper 
to the womb during pregnancy or parturition, you will do well 
to seek for therapeutical indications in the history of that abnor- 
mality, whether it be of ante-par 'turn oy post-par turn origin. And, 
if the other incidental indications correspond with these, which 
are cardinal, so much the better. But let me warn you not to be 
misled by the occasional pathological contingencies of the case 
merely. 

There is a wide and essential difference between a case of men- 
orrhagia which depends upon a defective involution of the womb, 



360 THE DISEASES OF WOMEN. 

whether it be chronic or acute, and one of excessive menstruation, 
caused by uterine polypi, fibroids, cancer, cauliflower excresence, 
ovarian disease, chronic metritis, or an impoverished condition of 
the blood. This case is typical of a certain kind ot monorrhagia, 
and I am speaking only of this particular variety. The reason why 
our best practitk ners give comparatively few remedies, is that they 
learn to classify their cases in this practical way, and to group 
their remedies accordingly. When such a classification is impos- 
sible, they are compelled to proceed on the old sui generis plan. 
But in our day, when the means of forming a proper differential 
diagnosis are so multiplied and so accurate, these exceptions must 
be very rare. 

That the secale not only causes the parietes of the womb to 
contract, but also has the specific effect to stimulate the absorption 
of an excess of its tissue, is shown in the recent experiment in 
Avhich its active principle, ergotine, has been injected sub-cutane- 
ously for the cure and removal of uterine fibroids. 

Those of you who have ever given china in haemorrhage after 

delivery, whether in abortion or at term, are aware of its virtues. 

For the relief of a familiar train of symptoms of 

Indications for china. . . . , , . . ,. , 

this kind, and which are referable to relaxation 
and lack of tonicity in the uterine muscular fibre, even secale is 
not a more efficient remedy. The power of cinchona to produce 
a decided effect upon the muscular coat of the womb, is also shown 
in those cases ot tardy labor, in which a few doses of quinine 
have caused the most powerful expulsive pains, emptied the uterus, 
and induced its cannon-ball contraction as a security against 
flooding. 

And so, likewise, of sabina, ustilago, trillin, and ipecacuanha, 
which are so often and so unwittingly prescribed for the relief 

and removal of this identical condition. Doubt- 

remed"es! 0nSf0r0ther less ' tbese remedies, and perhaps many others, 
have a curative relation, not only to acute and 
recent, but also to chronic and complicated cases of sub-involution 
of the uterus. I wish you might bear this fact in mind. 

It is very important for this class of patients to abstain from walk- 
ing and from standing for a long time. With the approach of the 
monthly period, and until the flow has entirely ceased, they should 
keep the recumbent, or, better still, the horizontal posture. 



SUB-INVOLUTION OF THE UTERUS, ETC. 361 

For, no matter how appropriate the remedy that is chosen, an 
opposite course would induce a hypostatic congestion, and subse- 
quent haemorrhage, with uterine prolapse or procidentia, and a 
perpetuation of the puerperal hypertrophy. This woman will take 
a dose of secale cor. 3d decimal dilution, three times each day. 

SUB-INVOLUTION AND RECURRENT ABORTION. 

Case. — Mrs. V , aged twenty-two, has been married fifteen 

months. In that time she has had three miscarriages ; the hrst at 
four months, the second at three and one-half months, and the third 
at three months. Prior to* this experience she was always well ; 
she used to weigh two hundred and five pounds, now her weight 
is one hundred and forty-eight pounds. The first abortion was 
caused by a fall upon her back. She kept around for a Aveek after 
the tall, had no pain or especial inconvenience, and at the end of a 
week miscarried without pain. The now lasted about three days ; 
she remained in bed for nine days, and then got up, but, as she 
did not feel very well, she took to her bed again and kept it for 
four days more. Then she felt well and returned to her duties. 

The second abortion was caused by stooping and lifting a wash- 
tub. This was done in the morning. She began to flow at once, 
and at nine in the evening the foetus was discharged. She had no 
real pain, but kept her bed three days. 

The third came on after putting up the clothes line, and hanging 
some heavy wet clothes upon it. This time she was in her bed for 
nine days. 

The last abortion occurred six weeks ago. She had no physician 
in either case. Last week, or five weeks after the third " mishap," 
she had her menses, the flow continuing for six days. At' that 
time she had more pain than usual with the discharge. This, she 
says, was the first and only time that she has menstruated since her 
marriage. 

This case affords an excellent illustration of the natural history 

of abortion, (1,) because the patient is intelligent and honest 

enough to o'ive an account of her experience ; 

A rare case. i « n t ttt 

and (2,) because she did not have a doctor, either 
before, during, or after her "mishap." For once, therefore, we 
have a case of the kind in which the patient is frank enough to 
tell the whole truth, and at the same time, is free from the mis- 
chievous effects of professional interference. 

Although this woman has been married only a little more than 
a year, she has already had three abortions ; one at the fourth month, 



362 THE DISEASES OF AVOMEN. 

another at three and one-half months, and a third at three 
months. Her case is one of recurrent abortion. 

^Frequency of abor- j t doeg ^ fuUy iUustrate wlmt lms been gtyled 

the "habit" of aborting, else it would almost 
invariably have occurred at the same period of pregnancy, and, 
having: begun at the fourth month would have continued to recur 
at very nearly the same date. 

When abortion occurs repeatedly, it may assume a regular type, 
in which case it most frequently happens at the month. Or, as 

in intermittent fevei% the type may change, and 

Types of abortion. . . ,,-, ; 

it may anticipate, or come earlier, as it has done 
in this instance. Sometimes the type is retarding, and a woman 
who began by aborting at the fourth month, will end by miscarry- 
ing at the sixth, or at the seventh month. And, whether the- 
subsequent "mishaps" are earlier or later than the first, there 
is a curious tendency to respect the regularity of the monthly 
cycle, and, if they do not occur at the month, to happen half way 
between the periods. You will observe that each time this woman 
has aborted since the first attack, her pregnancy has been shortened 
just two weeks. 

My own observation leads me to conclude that the more removed 
the date of miscarriage from the time in the month at which men- 
struation would have occurred, the less the probability that a 
diseased state of the ovaries has had anything to do with causing 
the trouble. Exceptionally, ho wever, as in inter-menstrual dysmen- 
orrhea, the ovarian influence may be most pronounced in the 
middle of the month, and hence abortion, or miscarriage, from 
ovarian disease might occur at that time also. 

It is morally certain that, when this woman aborted at the fourth 

month, it was not in consequence of metritis ; because she had no pain 

from first to last, neither after the fall, nor yet 

Peculiar cause of . . * -i i 

with the expulsion 01 the embryo. And what 
was true of the first case, was true of the others also. Her singu- 
lar exemption from suffering is also due, in no small measure, to 
the rest in bed which she took after each of the abortions, and to 
keeping off her feet, as if she had been delivered at term . For there 
is no such prophylactic of post-puerperal metritis as rest in the 
horizontal posture after the womb has been emptied of its con- 
tents, whether prematurely or not. 



SUB-INVOLUTION OF THE UTERUS, ETC. 363 

The treatment of abortion, and of its sequelae is sometimes very 

difficult because of the impossibility of knowing what has caused 

it. But ill this case, or rather in each of the 

Treatment. . 

cases under review, the exciting cause was 
traumatic; first our patient fell upon her back ; the next time she 
stooped and lifted a wash-tub, and the third time she strained her- 
self with the arms raised above the head. The etiology in this 
case is, therefore, very plain, and it sometimes happens that a 
disease is already half-cured when you know what has caused it. 

It may, perhaps, appear strange to some of you that so slight 

an accident should produce such serious results, especially in a 

healthv-lookino-, vigorous woman like our 

Peculiar susceptibility. * 

patient. But it only proves that she was sus- 
ceptible to the action of this class of causes, which, in Avomen who 
are differently constituted, might have had no such effect. There 
are those who can undergo almost any kind of physical exercise or 
fatigue without the risk of abortion. Some women work hard 
throughout their pregnancy, and others travel and inc*ir the 
greatest risks by sea and land without any mischievous results. 
But there are those in whom a misstep, a tit of coughing, or strain- 
ing at stool, may be sufficient to arrest the development of the 
ovum, and to bring about its expulsion. 

But what shall we prescribe for this poor woman? Is my duty 
discharged to her and to you when I have ordered a few powders, 
and told her to come again? A moment's reflection assures me 
that, under the present conditions, she would probably abort as 
often as she conceived. Her predisposition to abortion is partly 
original, and partly acquired. If we suppose that her fall was 
severe enough to have caused a perfectly healthy woman to mis- 
carry, we cannot think, other things equal, that the slighter shocks 
should afterwards have had such serious consequences. There 
must have been something in her clinical history to predispose her 
to a repetition of the accident. 

And that something which is at the bottom of the difficulty, is 
what we want to cover with our prescription. In fifteen months 

she has had her menses but once. Three times 
rest. 6 imP ° r aDCe ° ni ^hat iuteival, in consequence of a fruitful 

conception, the womb has begun and continued 
to develop until it was suddenly and forcibly emptied of its con- 



364 THE DISEASES OF WOMEN. 

tents. Having the good sense to go into a puerperal quarantine, 
she dodged the contingencies of haemorrhage, and of active inflam- 
mation. But, before the uterus could possibly have recovered 
itself, before its involution was half finished, before menstruation 
was resumed, gestation had begun again. And this process has 
been repeated twice already. 

The first rational indication is to provide against such an experi- 
ence in future. For nature would continue to resent such a disregard 
of her laws. The womb must rest, and recover its tone, as well 
as its size and form. We must take care that she menstruates 
regularly. And she should be very cautions about becoming 
pregnant again under six months or a year, when with proper care 
meanwhile, she might be able to reach her term without any acci- 
dent. 

She will take calcarea phos. 3d trituration, twice daily for one 
week, and then arnica 3, one dose every alternate night. 

[One year later this woman became the happy mother of a 
healthy and vigorous child.] 

SUB-INVOLUTION AND CHRONIC METRITIS OF EIGHTEEN YEARS 

DURATION. 

Case. — Mrs. Z.— , aged forty- three, is the mother of three children, 
the youngest of which is eighteen years old. She has had no mis- 
carriages. She has not been well during the long interval, but 
has suffered from articularrheumatism,menorrhagiaand prolapsus. 
She has had much local treatment by esc haro tics, for an alleged 
uterine ulceration. There is great weight within the pelvis, 
especially in advance of the monthly flow, at which time she is 
compelled to keep to the bed or couch. The menses are very 
copious, and are accompanied by a great deal of pain. She did 
not nurse her last child. Her last labor was very prolonged, and 
finally was instrumental. 

It sometimes happens that the post-pa rtum involution of the 

uterus is interrupted even when the patient has suckled her child. 

If the menses return prematurely, and recur 

Causation. •%■,-, i . i 

frequently, the flow will be menorrnagic and 
the conditions will be very similar to those in which the puer- 
peral involution is interfered with by endo-metritis. This is the 
condition which predisposes to chronic metritis as a coincident 
affection. The lack of the pioper tonic contraction of the uterus 



SUB-INVOLUTION OF THE UTERUS, ETC. 365 

favors the sub-involution, and the menstrual congestion precipi- 
tates the metritis. 

An intimate knowledge of the special pathology of sub-involu- 
tion is essential to its proper treatment. The best evidence of this 
fact is found in the method of treating it indis- 
Not always the result crimiuate iy as j t it were always the result of an 

of inflammation. f ' J 

inflammation. You should bear in mind the 
clinical rule that, unless a woman has suffered from some form of 
metritis in child-bed, or unless it is the consequence of too early 
menstruation after her delivery, she is not likely to have sub-in vo- 
lution and metritis at the same time. 

The case before us is, however, an exceptional one. We can- 
not learn her puerperal history, neither can we estimate the mis- 
chief that has been done in her case by cauteri- 

Physical si°*DS. 

zation. The menorrhagia and the pain at the 
month, as well as the inflamed condition of the cervix, which you 
observe in the field of the speculum, are so many evidences of 
metritis. The depth of the uterus, which, as you see is five inches, 
discloses the condition of defective involution that has existed 
for eighteen years. There is also a laceration of the cervix which 
must have occurred at the time of her delivery. 

It is a question whether Emmets' operation should properly be 
the first step in the cure; or if we should try to fulfill the physi- 
ological indication of securing the contraction of the uterus as a 
means of putting an end to the menorrhagia, the xnetritis and the 
prolapsus. For the present she will take the secale cornutum 2, 
four times a day. 

SUB-INVOLUTION, CHRONIC METRITIS, MENORRHAGIA, AND PROLAPSUS. 

Case. — Mrs. S., aged twenty-six, had a miscarriage at the fourth 
month of her first pregnancy, five months ago, in consequence of 
which she was confined to her bed for six weeks. The menses 
were very irregular and copious, with bearing-down pains when 
standing or walking, with great weight in the pelvis. During- 
the monthly flow, this weight and pressure are so increased, that 
she is obliged to keep her bed most of the time. This was her 
first visit to the clinic. She had been cauterized for some time 
for uterine ulceration. 

I have had this case placed upon the table in order to show you 
that sub-involution does not always depend upon a laceration of 



366 THE DISEASES OF WOMEN. 

the cervix uteri. The depth of the womb is four and one-half 
a practical lesson. inches, and the uterine epistaxis and the pro- 
lapsus are the natural and necessary conse- 
quence of its non-involution. It yas about as stupid to cauterize 
the wcmb in this case as it would have been to have put the tinc- 
ture of iodine into its cavity, or to have propped it up with a 
pessary. 

[This patient continued to report every week at the Clinic. 
She was examined locally from time to time, but no topical appli- 
cations of any kind were made. She took nothing but the secale, 
and improved from the first. In ten weeks the uterus measured 
only three inches, and the metritis, the menorrhagia and the pro- 
lapsus having disappeared, she was discharged cured.] 

SUB-INVOLUTION AND RETRO-DISPLACEMENT OF THE WOMB. 

These two lesions not unf requently coexist, both of them dating 
from child-birth. Sometimes a deep laceration of the uterine 
cervix will account for them, but the condition is quite as likely 
to depend upon a torn perineum. In such a case it may be difficult 
to decide what course to pursue in the treatment. My preference 
would be to stitch up the cervix and then to put the - patient upon 
the proper internal and local treatment, as already advised, and 
finally to repair the perineum. The success of this consecutive 
treatment, which is partly medical and partly surgical, will depend 
upon the persevering use of the former, and the greatest possible 
care in the performance of the latter. 



LECTUKE XXIII. 

PELVI-PERITONITIS. 

Ftlvi-Peritonitis.— Clinical history of, Case.— varieties,— Symptoms, the pain and its special 
characteristics,— the tympanitis, the facial expression, the temperature and pulse, the 
decubitus, the nausea and vomiting-, the effect upon the menses, the chill and thirst, 
the stage of effusion, the fixity of the uterus, the peritoneal tumor, the reflex disorders. 
—Causes. Case.— Prognosis— Treatment both local and general. Cases. 

Clinical History . — Although pelvi-peritonitis is much the more 
frequent with those who have borne children, or who have suffered 
from a miscarriage, it is not necessarily a post-puerperal affection. 
Seventy-five per cent of the cases are consecutive upon labor, and 
twenty- five arise from sources which are non-puerperal. 

Compared with inflammation of the uterus proper, it is relatively 
about as frequent as pleurisy when compared with pneumonia. 
Indeed, if the truth were known, I have no doubt that there are 
more cases of pelvi-peritonitis than there are of pleurisy. And 
yet some of your preceptors may tell you that they have never 
seen a case of it. 

Case. — Mrs. , came to me from Alabama. Her clinical his- 
tory was as follows: She was twenty-two years old, and had been 
married eight months. Three months after marriage she had an 
abortion at the second month, which was induced by fright on a 
railway train. She had labor pains for twelve hours before the 
ovum was extruded, and was confined to her bed for three weeks 
afterward, during which time she seems to have had a sharp attack 
of metro-peritonitis. 

From that time she has had a great deal of pain in the right half of 
the pelvis. This pain was diffuse and not localized, or of a burning 
character, as in ovaritis. It is however, very much aggravated at 
the period, when she is compelled to go to bed and stay there until 
the flow has ceased. At first the monthly discharge begins with- 
out pain, and geneially without her knowledge, but in a period 
varying from half an hour to two hours, the suffering begins and 
does not cease entirely until the flow stops. The character of the 
flow is natural. 

These intra-pelvic pains are very much aggravated by riding in a 



368 1HE DISEASES OF WOMEN. 

rough carriage, on horseback, or over a rough road; by coughing, 
or rapid breathing from any cause ; by constipation and unusual 
retention of the urine ; by coitus, the introduction of the specu- 
lum, and of the uterine sound; and also by the occurrence of a 
storm. 

Local examination reveals a pouching downwards of the right 
lateral cul-de-sac, with great tenderness and an inclination of the 
body of the uterus towards the left side. The tenderness extends 
forward to the region of the bladder and is so marked that, after 
being introduced, 1he most careful separation of the blades of a 
Cusco speculum causes an unbearable pain, especially in the right 
half ot the pelvis. The passage of the sound, which was also very 
painful, showed that there was no uterine deviation, except in 
the direction already indicated. 

Varieties. — Authors have recognized many varieties of pelvic 
peritonitis. Thus they speak of the common, the benign, the 
chronic, the suppurative, the menstrual, the recurrent, the hemor- 
rhagic, the tuberculous, and the cancerous forms of this disease. 
But these divisions are unnecessary, except as they serve to qualify 
the cause, the course, and the complications of this form of peri- 
tonitis. 

Symptoms. — There are several stages in this disease, and the 
symptoms vary in each of them. Thus we have the stages ot con- 
gestion, effusion, adhesion, resolution, and of 

Different stages of. c . ™ ,, 

suppuration, Iney are not all present m every 
case, for if the trouble is arrested with adhesion, that will be the 
end of it, unless there is a relapse ; and so also with the other modes 
of termination. Many cases, however, pass into the chronic form 
and develop a sort of cachexia that is really incurable. 

The first, or the congestive stage is accompanied by pain which 
is usually, but not always, preceded by a chill. The pain is sharp, 

darting and lancinating in character, like that 

of ordinary peritonitis. Exceptionally it comes 
on without any prodroma; and still more rarely the pain is lack- 
ing altogether. 

The pain is located at the base of the abdomen, low down over 
the superior strait, but it usually inclines toward one hip more than 

the other. Its grand characteristic is that it is 
^special characteristic aggravated by mo tion, by pressure, by increased 

rapidity of respiration, by standing, and by the 
effort to urinate, or to evacuate the bowels. On account of this 



PELVI-PEF1TCXITIS. 369 

pain there is a marked and decided intolerance of the touch, 
whether it is applied by the vagina, the rectum, or in the com- 
bined form. In some cases this intra-pelvic pain is so decidedly 
increased by the touch and by pressure, that we cannot use the 
speculum to any advantage, or even, perhaps, succeed in passing 
it at all. This is especially true in case of tne pelvic peritonitis 
which is contingent upon cancerous infiltration about the neck of 
the uterus and the vagina. 

In the second stage, the pain is less acute and agonizing, and, 
According to the site and extent of the effusion, takes on a drag- 
ging, forcing character, with a feeling as if the 
womb would be expelled, and with more or less 
tenesmus of the bladder and the rectum. 

Another symptom which is seldom lacking is abdominal tym- 
panitis. This may be local or general , and it may come on abruptly 
ac the onset of the disease. The cause of the 
meteorism, the colicky pains, and of the disposi- 
tion to vomit also, in this disease, is the adhesion of folds of the 
intestine to parts that are naturally free from such an attachment. 
Half the women who have tympanitis, menstrual colic and vomit- 
ing at the " month," are really ill with pelvi-peritonitis, although 
perhaps in so mild a form that it has not been recognized. 

In acute cases the face is pale and anxious, but in chronic cases 

it may have the dull earthy hue of coprremia. When it follows 

abortion, especially if there has been a, great 

The facial expression. ■,.'■,«,""•-.■• ... . 

deal oi haemorrhage, you will sometimes recog- 
nize the puerperal tint of M. Bordon. 

In pelvi-peritonitis, unless it be in the puerperal form, the 
temperature is not usually very high. It ranges from 101° to 

103°, rarely reaching 104°. But the pulse has 

The temperature and .., ... 

the pulse. the characteristic trequency oi peritonitis, al- 

though it is not so small and filiform as it is in 
diffuse peritonitis. 

The dorsal decubitus is the usual one, and the limbs are drawn 
up, in order to relax the abdominal parietes, as in puerperal peri- 
tonitis. In the chronic form of the disease, 

The posture taken. 

however, this posture may be assumed only at 
the monthly period, or after exercise, as in riding or walking. 
Sometimes the patient finds great relief from having the hips 
raised.- u 



370 THE DISEASES OF WOMEN. 

In very acute attacks, and in the menstrual and the recurrent 

forms of the disease, there is apt to be more or less vomiting. 

Obstinate vomiting at the month is more likely 

Nausea and vomiting 1 . . f\ ■ 

to be due to this than to any other cause ; and 
you should not forget that it may sometimes be relieved almost 
instantaneously by lifting a prolapsed womb into its proper posi- 
tion. The vomiting is more frequent in pelvic peritonitis than it 
is in pelvic cellulitis. 

The menstrual flow is sometimes diminished, sometimes suppres- 
sed, and at other times is very much increased in quantity. When 

this form of peritonitis occurs in those who have 

mens^ UPOn ^ never bsei1 P re g* liant > ^ is ] ike ty to induce either 

amenorrhcea or dysmenorrhea ; but as a post- 
puerperal affection, in the great majority of cases at least, it is 
accompanied by menorrhagia and sometimes by metrorrhagia. 

Unless there are septic or pysemic complications, or extensive 

suppuration with relapses, the initiatory chill does not repeat 

itself. There may, however, be inordinate 

thirst, with or without tolerance of cold water, 

and a less of appetite. 

When the local congestion has continued for a period varying 

from a few hours to several days, it is relieved by the effusion of 

serum, as in pleurisy or synovitis. When this 

The stage of effusion. . J . . J - , , J T n 

has taken place the local symptoms, as revealed 
by the "touch," are entirely changed. Now three things are to- 
be especially noted; (1) the diminution of the 

Three points to be ob- _ ,. 

served in local exam- local pam on pressure, (z) the fixation ot the 
uterus, and (3) the presence of a tumor at some 
portion of the roof of the vagina. 

Tins diagram will odve you an idea of the formation of the 
lateral pouches made by the dipping of the peritoneum at the 
sides of the uterus. The retro-uterine depression is more capacious, 
and comes lower down, especially upon the left side. 

The more extensive the circum-uterine inflammation, and the more 

prolonged the first stage of the attack, the greater the liability of 

the uterus to become anchored by adhesions. If 

uSrus fiXlty ° f ^ the case is complicated with cellulitis, or with 

tuberculous or cancerous infiltration, you may 

find the uterus quite immovable. Fixity of this organ is very apt 



PELVl-PERITONITIS . 



371 



to follow in case of pelvi-peritonitis that has been caused by a mis- 
chievous use of the sponge-tent?, the hysterotome, caustics, and 




The peritoneal tumor. 



Fig. 32. The Utero-lateral Peritoneum. 

even the wearing of an illy adjusted pessary. It sometimes creeps 
on insidiously as a sequel to endo-metritis, membranous dysmen- 
orrhea, and partial or complete stenosis of the cervix uteri. 

When the effusion has taken place, the fluid drops into the most 
dependent portion of the peritoneal cavity. Hence the swelling 
formed by the accumulation will naturally be 
found at the roof of the vagina, and as a rule, 
either laterally or posteriorly. The most frequent seat of this 
tumor is at the Douglas pouch, which, if the quantity of fluid is 
large and limited to that vicinity, will be so inverted as to pro- 
trude behind the cervix. If this inversion and protrusion of the 
roof of the vagina takes place on all sides it will throw a kind of 
collar about the cervix which is peculiar and cannot be mistaken. 
Sometimes it is of limited extent and may occupy one side of the 
pelvis only. Even when the effusion is very extensive the tumor 
that is formed does not very often rise above the superior strait. 
And, because the peritoneum does not extend below the level of 
the posterior lip of the cervix, it does not drop very far down- 
wards, or reach the vulva as may happen in pelvic cellulitis. 

To the touch, the feel of the tumor is hard, irregular and im- 
movable. In the relapsing form of the disease it is almost always 
painful on pressure. Like the tumor of pelvic hematocele, the 



372 THE DISEASES OF WOMEN. 

firmness of its texture is more pronounced the older it is, or at 
least, until suppuration has taken place and an abscess has formed. 

If the attack terminates by adhesion, or by resolution, this tumor 
may disappear altogether. Such a result may happen spontane- 
ously, even when the tumor is as large as an orange, or the foetal 
head. This is the class of tumors which are sometimes mistaken 
for ovarian tumors, and which are reported in the journals as cured 
by all sorts of remedies. 

In the chronic form of pelvi-peritonitis menstrual relapses are 

the rule and not the exception. It seems that, the more the uterus 

and its appendages are bound clown bv the false 

Menstrual relapses in. ', 

membranes which have resulted from previous 
inflammation, the more intolerant it is of the monthly nisus. For 
this reason the worst cases of dysmenorrhcea, which develop into 
menorrhagia and drag a patient down, are dependent upon this 
variety of peri-uterine inflammation. 

The bands which fasten the uterus to the Fallopian tubes and 

the ovaries, the bladder, and the rectum sometimes interfere very 

decidedly with their functions. The extension 

Reflex, digestive, and f th j nflanimation to the per itoneal coat of the 

other disorders. . ■ •. . 

intestines may result in more or less of strangu- 
lation and agglutination and thus interfere very materially with 
the nutritive function. From these causes, chronic pelvic peri- 
tonitis is almost always accompanied by a series of reflex disorders, 
such as spinal irritation, headache, hysteria, and paralysis. 

There is a form of pelvi-peritonitis which results from Menor- 
rhagia, and which, besides being accompanied by sterility, is very 
difficult of cure. It is very likely to occur in the 

Gonorrhoea! pelvi- j ^ f th ho haye been dissipated ill 

peritonitis. / 

their early years, or who, because of absence 
from home and other circumstances, are led to the practice of 
wrong habits. These cases originate in a gonorrheal ovaritis, 
and are as unmanagable, if you fail to recognize the taint, as some 
cases of crusta lactea are from a similar cause. 

Causes.- — Much of the confusion of medical writers concerning 

pelvic peritonitis is attributable to the fact that 

A source of confusion. „ ' , , .-, , e , , , 

most of them, and the best of them, have 
insisted that it was always consecutive upon metritis. Bernutz, 
whose excellent clinics I attended in Paris, is the leader of this 



PtLVI-PERlTONITIS. 373 

party. *Jousset and others, however, recognize a variety of causes 
which may or may not be connected with any form of metritis, 
whether puerperal or non-puerperal. 

These causes include abortion, an extension of endometritis 
through the oviduct to the peritoneum, as sometimes happens in 
the lying-in, salpingitis, ovaritis, metritis, gonorrhoea, pelvic- 
haematocele, uterine and ovarian tumors, the extension of entero- 
peritonitis, cystitis, recHHs, uterine deviations, coitus and the use 
of injections during menstruation ; and the traumatic effects of 
operations about and within the cervix uteri, more especially cau- 
terization, the passage of sponge-tents, forcible dilatation, incision, 
and amputation of the same, the resort to intra-uterine injections, 
mid the wearing of mal-adjusted pessaries. 

I have long been satisfied that a large share of the non-puerperal 

cases of pelvic peritonitis especially, are of a rheumatic nature. 

Some of the worst examples that I have ever 

From rheumatism. . .. 

seen, belonged to this clans, and have occurred 
in women who have never been pregnant, and in whom there was 
an evident translation of the rheumatic lesion from other serous 
membranes to the peritoneum. Here are the notes of a case of 
this kind which was sent to me by Dr. C. C. Brace, of Boulder 
Colorado, and which is still under my treatment. 

Case. — Mrs. , aged thirty-eight years, was married fourteen 

years ago, but has never been pregnant. She has been ill for four 
years. She was first taken violently with spinal meningitis, and 
this illness continued from December until April. As soon as 
the back was better she began to have very severe pains within the 
pelvis. In a little while the spinal suffering was entirely substi- 
tuted by the pelvic pain and distress. Five years before, she 
had been operated upon for vaginismus; but now a similar spas- 
modic condition of the vagina came on again, ar>d the operation 
was repeated in the month of July. About the first of October 
she began to sit up again, but, in a fortnight became worse and 
complained of very severe intra-pelvic pain and distress. She had 
paroxysms of this suffering which occurred at the month, and at 
other times also in consequence of the least fatigue or worry. 

After the second operation she returned to Nebraska in January, 
where she remained two months on a visit ; but while there the 
old pain in the back and neck returned. The consequence was that 
she was obliged to return to Colorado. There she was confined to 
her bed for eight months, during which time the spinal symptoms 

♦Lectures on Clinical Medicine, translated by Ludlam, Chic-go, ] age 268. 



374 THE DISEASES OF WOMEN. 

almost entirely disappeared and the pelvic suffering came back 
again. Added to this she began to have spells of intractable 
vomiting from prolapse of the uterus, to which she has now been 
subject for two years, and which my friend Dr. B., and myself 
also, have frequently relieved by repositiug the womb. 

The menses return regularly every four weeks, being sometimes 
a day or two in advance. The flow continues four days, is normal 
in quality, and has never been very copious. The local symptoms 
are those of an unmistakable pelvic peritonitis. 

Other accidental causes have been assigned for this form of peri- 
tonitis. A case is reported in the British Medical Journal, in which 
the attack was induced in a young girl, by swinging. My friend 
Dr. W. A. Sheppard, of Dundee, 111., called me in consultation a 
few months ago to a woman who had had a severe attack of pelvi- 
peritonitis with a sudden ante version of the uterus, that was 
caused by her being swung over and over several times in a ham- 
mock. 

Diagnosis. — Pelvic peritonitis is much more likely to be mis- 
taken for pelvic cellulitis than for anything else. But, since I 
have not yet spoken of pelvic cellulitis, it will 
" be best to defer my remarks upon the differential 
diagnosis of these two affections, until the next Lecture. 

In pelvic hematocele the recent tumor is soft and yields to 
pressure; but as it grows older it becomes more firm and unyield- 
ing. On the contrary the tumor in pelvi-peri- 

Jrompelvieha B mato- tonitis ^ j^ at first) and become s soft and 

fluctuating when pus has formed in it. As a 
rule the haematomatous tumor is much the larger of the two. The 
constitutional symptoms are very different. Peritonitis often 
attends upon hematocele either as a cause or as a complication. 
We shall speak of pachy-peritonitis and its resulting haemorrhage 
at another time. 

The diagnosis of pelvic peritonitis from parenchymatous metritis 
is very clearly given by Gkierin:* " In both these affections the 

invasion of the disease may be announced by a 
From parenchy- chill; both are accompanied by acute pain, and 

matous metritis. * J \ m 

we may find in the case of metritis a tumor which, 
reaching above the pubis, may lead us to believe that it is due to 

*Lecons cliniques sur les maladies des organes genitaux internes de la femme, par 
Alphonse Guerin, etc., Paris, 1878, page 366. 



PELVI-PEUITOMTIS. 375 

pelvi-peritoiiitis. But the vaginal touch will soon dissipate our 
doubts on that question, hi metritis we shall recognize that the 
tumor is movable, whilst in peritonitis it is fixed by adhesions as 
firmly as it it were nailed. In this form of peritonitis the culs-de- 
sac are filled by the tumor, while in metritis they are free. In 
metritis the cervix uteri is larger than normal, its lips are thick 
and everted. The os uteri is not changed either in its volume or 
its consistency in pelviperitonitis." 

Jousset differentiates between pelvic peritonitis and abscess of 
the iliac fossa as follows : *" In abscesses in the iliac fossa 1 , if they 

are superficial, the tumor is not perceptible by 
iiiIc°fossa. SCeSS ° fthe the vagina, but extends directly towards the 

horizontal ramus of the pubis. When they are 
deep-seated and profound, there is retraction of the thigh upon the 
pelvis, through irritation of the psoas muscle ; very often oedema 
of the labia majora, and a cleep-seated swelling in the external 
portion of the iliac fossa, which afterwards is felt in the lateral 
walls of the vagina, and towards the horizontal ramus of the os- 
pubis." 

Prognosis. — The simple adhesive form of this disease may run 
its course and terminate favorably in a month or six weeks ; but 

more serious cases will require more time and 

vJSety! adhe8iVe care - In both > an(i ilia11 forms of pelviperi- 

tonitis there is a marked tendency to relapse, 
and the slightest imprudence, exposure or over-exertion may pre- 
cipitate a fresh attack. This peculiarity is so pronounced, that an 
experienced gynaecologist will be very careful in promising to cure 
this affection, or in claiming that he has ever succeeded in doing 

SO. 

When the adhesions are very extensive they complicate the case 
and protract the cure, by binding the uterus and its appendages 
and the intestines in unnatural positions, so as greatly to increase 
their tendency to disease, and to increase the suffering of the pa- 
tient also. For this reason the most tedious cases are sometimes 
characterized by an absence of the tumor. This is especially true 
in such as are non-puerperal, as the gonorrhceal and the rheumatic. 
Do the best we can, some of these cases will continue for years 
without any permanent improvement. 

* Op. citat. p. 275. 



376 



THE DISEASES OF WOMEN. 



In attacks of pelvi-peritonitis which are secondary upon puer^ 
peral metritis, salpingitis, and ovaritis, as well as in those which 

follow a prolonged course of local treatment by 
seoondrryTo r r ms raland escharotics, and the harmful expedients of 

uterine surgery, the result will vary with the 
duration and severity of the previous disease, or of the treatment 
to which she has been subjected, and her remaining constitutional 




Fig. 33. Peritoneal Adhesion of the Tubes and Ovaries to the Uterus. 

vigor and vitality. If the primary disease has been protracted, 
if she is of a scrofulous habit, if her strength has been exhausted 
by nursing, or impaired by her inability to eat well and to digest 
her food, if she has had menorrhagia, or repeated abortions, the ten- 
dency of the tumor to develop into an abscess will be very much 
increased. 

Pelvi-peritonitis is comparatively frequent in delicate women 
who are predisposed to tuberculosis. Thiscom- 
jects! UberCUl ° USSUb " Potion, or the possibility of it, should lead 
you to qualify your prognosis. 
Treatment. — The treatment is local and general. The uterus 
the folds of the peritoneum, that a moment's 
reflection will convince you of the importance of 
rest for the patient when that membrane is in- 
flamed. If a woman cannot wink without 
changing the position of the womb in its relation to other organs, 
or without tightening and stretching its ligaments ; and if these 



is so 



m 



The importance of 

rest. 



PELVI-PER1TON1TIS. 377 

means of support are composed most largely of peritoneum, it is 
evident that bodily rest is indispensable to the cure of pelvi-peri- 
tonitis. No advice is more harmful in these cases than to insist 
that the poor victim must get up and go about, must exercise 
vigorously, and walk or ride, perhaps on horseback, or travel about 
as if she were well. Certain modes of exercise are very injurious, 
as for example, running a sewing machine, sitting for hours at a 
piano, or standing all the day long in a store, or all the night at a 
party. 

When these habits are resumed after an attack of peritonitis, 
no matter how slight it may have been, we cannot expept that the 
inflamed surfaces will ever be restored to their ante-movbum state. 

A mode of exercise including the proper postural treatment for 
some of these cases has recently been suggested by Dr. Van de War- 
ker.* This mode consists in placing the patient in a hammock. Dr. 
W. says: " I have used the hammock several times, and have never 
failed to observe more or less relief as an apparent result. If we 
examine the matter we shall perceive good reason for such a result. 
The position of a patient in a hammock is one peculiarly adapted 
to relieve tension upon intra-pelvic indurations or adhesions; 
from head to heels, the patient is in a perfect bow, the pelvis 
elevated. The natural effect is, first, to relieve tension, or stretch ; 
second, to lessen hyperemia of the pelvic vessels by the elevation 
of the hips. All this, of course, relieves pain. 

" But we have a further effect not so easy to explain. A pecu- 
liar sedative effect seems to be due to the motion. We all know 
how seductive and soothing is the sense of langour that steals over 
the senses, while gently oscillating in a hammock. There is no 
doubt but the Lotus-like tendency has its force doubled in the case 
of a woman whose power of nervous resistance is weakened by 
disease, or put upon a severe tension by pain." 

The local expedients that may be of service consist in the use 

of hip baths of warm water, or vaginal injections of the same, the 

topical application of the bran poultice and 

other emollients, and the painting of the lower 

portion of the abdominal integument with Latour's oleaginous 

collodion. 

If the womb is out of place it should be carefully reposited, but 

Transactions of the American Gynaecological Society. Vol. 3, 1878, page 342. 



378 



THE DISEASES OF WOMEN. 



pessaries of all kinds are harmful, and cannot be borne. There la 
scarcely a week that passes in which I am not obliged to remove 
a pessary that is persecuting- some poor woman in this way. In very 
exceptional cases, however, an instrument with a perineal support 
may not only be tolerated, but of real service. All those which 
put the vagina upon the stretch, are mischievous, even in the 
milder forms of pelvi-peritonitis. 

Of late, excepting in local peritonitis with pelvic hsematocele, 
we never find it necessary to resort to opiates in these cases. There 
is an expedient which has the double merit of 
relieving pain and of being of direct benefit in 
curing the inflammation, and that expedient 
consists in the use of very warm or hot water, in the form of a 
vaginal irrigation. It is always available, and will assuage the 
pain as promptly and more efficiently than morphine. Its use can 
be repeated as often as necessary without any harmful results; 
nor does it in the least interfere with the action of the appropriate 



A substitute for 
opium. 




Fig. 34. Lord's Hot-water vaginal douche. 

internal remedies. Moreover, it is quite as useful in pelvic cellu- 
litis and in hematocele as in pelvi-peritonitis; and, since these 
affections may merge, or are apt to be mistaken for each other, 
this surely is an advantage. 



PELVI-PERITONITIS. 379 

To apply these injections (first recommended by Emmet), the 

patient should lie upon her hack with the hips raised. She should 

be undressed and go regularly to bed. Then 

Mode of applying the , . m i d . ftlshione d English bed-pan beneath 

hot-water injections. * , 

the hips, or bring them to the edge of the bed, 
and so arrange the rubber cloth beneath them that the water may 
flow into a basin or bucket upon the floor. The stream can be 
thrown by a syphon of plain rubber tubing, or by a syringe with 
a constant current. See Figs. 36 and 37. The temperature of the 
water, of which from two quarts to two gallons may be used at 
one time, may be gradually increased from U£T to 1(JS°. The 
operation may be repeated as often as necessary without any bad 
effects. 

Where there is much induration a tampon of cotton that has 

been saturated with the mixture of aconite, hamamelis, calendula, 

conium or chloroform, and <rlycerine, may be 

For the induration. -. . . . , . . ,, . . 

passed within the vagina, or pressed gently into 
the posterior cul-de-sac, and left there for some hours. If tne case 
is rheumatic, the hamamelis used in this way will give the most 
relief. 

Whatever may be said to the contrary, it is of the utmost im- 
portance in these cases to keep the bowels in a soluble condition. 

With women of sedentary habits especially, the 

^Obviate the constipa- begt ^^ remedies in ^ wor ld will not bring 

about the desired result while they continue to 
suffer from constipation, with the passage of hard, dry, scybalous 
stools. The same is true of the co-existence of haemorrhoids. 

I have seen cases of pelvi-peritonitis upon which no positive 
curative impression could be made by the resources of gynaecology, 
until they had been relieved of a harrassing 
cough. Every fit of coughing induced a fresh 
attack of the intra-pelvic pain and distress, and sent the patient 
to her couch or her bed. Sometimes such a cough may depend 
upon a coincident pleurisy, and the remedies that are suited to 
one will answer for both of these affections. 

The general treatment consists in the appropriate use of remedies. 
But Jousset is quite rio-ht when he says, that the 

0"PTIPT*£l1 1"T*f k 3l"TTlP"n1" 1 J 

special pathology of pelvi-peritonitis is so re- 
cently known, that we have no clinical and classical treatment 



380 THE DISEASES OF WOMEN. 

for it. He, however, recommends three remedies as being the 
most useful in the acute stage. These are aconite, colocynth, and 
cantharis. I must refer you to his work on Clinical Medicine 
for the special indications which he has given for their use. He has 
great confidence in the employment of the mother tincture of 
aconite, of which he says: "In very acute and 

Aconite. J . J 

severe cases Ave do not hesitate to prescribe twenty 
to thirty, drops of the mother tincture, to be taken within twenty-four 
hours; but where the attack is milder and not so threatening, the 
lower dilutions (the first, second and third) have always been suffi- 
cient. Whatever the dose or the dilution, the aconite should be 
continued while the fever continues to be violent.'' The indica- 
tions for this remedy are drawn from the character of the fever, 
and from the serous inflammation. 

I have long ago learned to have confidence in colocynth in some 
cases of pelvi-peritonitis. Dr." Richard Hughes relates that, in a 
case of poisoning by colocynth, the autopsy 
showed that the intestines were oflued together 
by a recent exudation of lymph;* and it has seemed to me that 
this remedy was especially adapted to those cases in which the 
disease had shown a disposition to involve the peritoneal coat of 
some portion of the bowel, or of the ovary. The symptoms which 
indicate it are colicky, cutting, tearing pains in the abdomen, and 
diarrhoea with rectal and vesical tenesmus. 

Where there is much tympanitis, with diffuse tenderness, neu- 
ralgic pains, nervousness, insomnia, flushing of the face, with 
dilated pupils and delirium, belladonna will be 
Belladonna and atro- f service> In a general way this remedy is 

pine. & J J 

useful to abort the congestive stage of pelvic 
peritonitis. If you are certain that it is indicated and relief does 
not follow its employment, you will sometimes do well to substi- 
tute a few small powders of atropine 3. If 
tardy menstruation is the cause of the conges- 
tion, you may drop the belladonna and substitute gelsemium. 

Bryonia should not be forgotten or overlooked in this connection. 
What Baehr says of it (Science of Therapeutics, translated by 

*A Manual of Pharmacodynamics. By Richard Hughes, L. R. C. P. Ed. Third Edition 
1876, page 315. 



PELV1-PERITONITIS. 381 

Hempel, Vol. I, p. 515) is certainly true. "Hartman's assertion 
that peritonitis cannot be cured without acon- 
ite, seems to us more applicable to bryonia. It 
comes into play at the most decisive period in the development 
of the disease, namely when Ave desire to remove the effused fluid 
as soon as possible .... In comparing the second stage of 
peritonitis with the pathogenesis of bryonia, we shall find that, in 
the majority of cases, this remedy is indicated by its physiological 
effects upon the healthy. It is almost certain that, under the in- 
fluence of bryonia, the exudation is reabsorbed without caus- 
ing any further derangement; hence, that no suppuration will take 
place. But the medicine should be used consistently ; we cannot 
expect to obtain results in a day that can only be obtained in from 
ten days to a fortnight." 

Apis mellifica is indispensable if pelvic cellulitis complicates the 

case, and if we desire to abort the tendency to all forms of pelvic 

abscess. If the effusion is lodged in the meshes 

Apis mellifica. . . ..,' . n-- 

ot the areolar tissue, the apis will do all tliat is 
claimed for bryonia when the serum has been poured out as a con- 
sequence of peritonitis. But it needs to be given in a low form, 
and frequently repeated. 

For the best of clinical reasons I have great confidence in the 
internal administration of terebinth in puerperal peritonitis; and 

likewise also in post-puerperal pelvic peritonitis. 

Terebinth. . . . 

In its effects upon the urinary organs it is closely 
related to cantharis, being also possessed of a wonderful influence 
upon the serous membranes. It is adapted to the relief of such 
typhoid and haercorrhagic states as are met with in typhlitis and 
dysentery ; and is useful in peri-cystitis also. In the form of pelvic 
peritonitis which is more or less complicated with cellulitis, occur- 
ing in weak and adynamic conditions of the system, more especially 
if there is pachy-peritonitis with hematocele, it is one of our 
very best remedies. I generally prescribe it in the second decimal 
trituration. 

When the attack arises from a metastasis of rheumatic inflam- 
mation directly to the peritoneum, it has sometimes been unwit- 
tingly cured by brvonia, belladonna, rhus tox., 

The salicylate of soda. . a ... , " , ,. ^. ,. , , T 

hamamelis, colocynth, and macrotm. Oi late 1 
have given the first, and sometimes the second decimal trituration 



382 THE DISEASES OF WOMEN. 

of the salicylate of soda in some of these cases with very decided 
benefit. It is indicated for the relief of the intra-pelvic pain and 
distress, especially when it is of a neuralgic or rheumatic character; 
but the more acute the case, and the more decided the diminution 
in the quantity of the urine secreted, and the absolute increase in 
the proportion of uric acid contained in the urine, the better the 
indication. 

There are three general indications for the use of macrotin in 
this disease, (l)the possible rheumatic character of the lesion; (2) 
the disposition to implicate the spinal muscles and 
ligaments indirectly, and (3) the nervous, and 
mental symptoms. This remedy has been extolled in a loose way 
as a kind of specific for rheumatic metritis, and for uterine neu- 
ralgia. These alleged cures, however, are lacking in the essential 
• elements of diagnosis, and, considering' the 

Do. in rheumatic per- . . . n , . .. .,. 

itonitis. greater re rati ve frequency of pelvi-pentonitis, 

it is more than possible that the results obtained 
by macrotin should rather be credited to its curative influence 
upon rheumatic peritonitis. 

It is not always easy to distinguish spinal irritation from a pain- 
ful condition of the spinal muscles that is very generally known 
as myalgia; but, it is necessary to do so, in or- 

Do. in peritonitis with . . 

spinal myalgia. der to obtain a clear indication lor macrotin in 

pelvi-peritonitis. For this remedy is not called 
for in the former case, while it certainly is in the latter. This indi- 
cation is confirmed by the occurrence of other reflex rheumatic 
pains, as for example, pleurodynia, intercostal rheumatism, the 
infra-mammary pain, and the pains which in chronic cases are 
located in the left side. 

I cannot give you a better illustration of the power of macro- 
tin to control the mental symptoms that sometimes accompany 
this disease than to cite the principal details of 
do for the mental a case wn ich I have already published in Jous- 

symptoms in. _ . 

set's Clinical Medicine. This is one of a num- 
ber of similar cases in which this remedy has benefited my patients 
and brought me no little reputation. 

Case. — Mrs. . came to me from Baltimore in 1876. She 

had been ill for four years, or since the birth of her last and only 
living child. Her condition was really deplorable. The menses 



PELVI-PERITONITIS. 3S3 

were regular, but scanty; there was much intra-pelvic pain and dis- 
tress, spinal myalgia, and sleeplessness with a complete loss of 
appetite. Mentally she was on the ' versre of insanity; nothing 
von earth interested her; her lovely boy, her sister, her friends, 
society, and the church were all very distasteful. She could not 
read or think with any diversion or satisfaction, and she became 
emaciated and wretched. 

She had treatment from both and from all schools of medical 
practice; had worn pessaries, and had passed through the purga- 
tory of leeching and blistering, starvation and hydropathy, but 
without being benefitted in the least. Locally there was an exten- 
sive abrasion of the cervix uteri to which I applied the oleagin- 
ous collodion. She was of a rheumatic diathesis, which, with the 
character of the pelvic and spinal suffering, and of the mental 
symptoms, indicated macrotin. She took this remedy, and this 
only, in the third decimal trituration. In a short time she began 
to improve, and in a few weeks was quite well again. Three 
years have now passed (1880) and there has been no return of the 
old trouble. She has gained in flesh, is rosy and hearty, and the 
centre of attraction for a large circle of friends. 

[At his sub-clinic on Friday October 15th, 1880, Prof. Ludlam 

showed the class three cases of pelvi-peritonitis which were in 

some respects remarkable. In the first of these, 

Case. 

the patient, aged 35 years, the mother of five 
children, the youngest of which was five years old, complained of 
severe pelvic pains which she has had since her last labor. Her 
puerperal history was very indefinite. The pain is limited to the 
right half of the pelvis and to the region of the umbilicus, but 
disappears from both localities upon her lying down. In search- 
ing for the cause of this relief by the change of posture, it was 
explained as follows : "When she is standing the uterus is prolapsed 
and drags upon its peritoneal supports, or in other words, upon 
the so-called uterine ligaments, consequently the inflamed mem- 
brane is put upon the stretch. But, when she lies upon her back, 
as was demonstrated to the class, the womb recedes of itself and 
its ligaments are relaxed. 

Besides, when she stands erect, sits, or walks about, there is a 
hernial protrusion at the umbilicus, which causes the pain in that 
locality. When she lies upon her back, the hernia being a small 
one disappears of itself, and the pain along with it. 

In the second case, there, was a clinical history of partial steno- 
sis of the cervix uteri and consequent dysmenorrhcea, for which 



384 THE DISEASES OF WOMEN. 

the patient had been treated surgically by incision three year& 
Cage before. After this operation she had suffered 

from an attack of peri-uterine inflammation from 
which she has never entirely recovered. For two years she 
has had a form of menstrual peritonitis. Of late, however, 
her symptoms have changed and she now complains of a burning 
pain in the vagina with great tenderness, which prevents the in- 
troduction of the speculum. On visual inspection the vagina was 
found to be the seat of a diffuse and very violent inflamma- 
tion of a non-specific character. The peculiarity of this consisted 
in the fact, that the vaginitis was consecutive upon the pelvic 
peritonitis, and that she had never had it before. 

In the third case there was an evident complication of pelvic 

cellulitis and a laceration of the cervix with the pelvic peritonitis. 

The patient also had rheumatism of the left 

Case. 

ankle-joint. The case had been under careful 
observation for some weeks, and there was no doubt about the 
diagnosis. The form of the laceration, which was shown to the 
class, is very well illustrated in the accompanying figure. 




Fig, 35. Bifid laceration of the cervix. 

Prof. L. said that the chief obstacle to the cure in this case 
was that, while the circum-uterine inflammation, more especially 
the peritonitis continued, an operation for the laceration of the 
cervix was contra-indicated.] 



LECTUKE XXIV. 

PELVIC CELLULITIS. — PELVIC ABSCESS. 

Pelvic cellulitis. Case.— The congestive stage— the stage of effusion— ditto of resolution- 
ditto of suppuration. Causes. Coincident diseases. Diagnosis. Sequelae. 

Of late years the physiology and pathology of the pelvic areolar 
tissue has attained a great and merited degree of importance. 
The whole theory of uterine displacements and of uterine inflam- 
mation is concerned in its clinical history. From the day in which 
Dr. Priestly's researches and dissections were published (1854), 
until Dr. Emmett's book was issued last year (1879), uterine 
pathology has undergone a complete revolution, and what was 
vaguely styled the " loose cellular tissue" has received such con- 
sideration as has not been bestowed upon any other tissue within 
the pelvis. I shall therefore, take especial pains to give you as 
correct an idea as possible of the subject of pelvic cellulitis, ot 
which you have already seen a number of cases in my clinic. 

The subject is a difficult one, more especially because the struc- 
ture involved is outside of the generative intestine, and is therefore, 
only indirectly accessible ; because this same areolar tissue is greatly 
modified by pregnancy, is more likely than almost any other 
structure to be injured during labor, and also because it has a puer- 
peral history Avith sequelae that are very peculiar and persistent. 
Another characteristic which complicates the study, and the 
treatment of pelvic cellulitis is the tendency to the formation of 
abscesses. 

PELVIC CELLULITIS. — PERI-METFJTIS. — PELVIC ABSCESS. 

Case. — Mrs. S , set, 30, was delivered by forceps of a dead 

child twelve weeks ago. Following this her physician said that 
she had puerperal fever. When she entered the hospital she 
complained of acute pain in the right iliac region, Which was ag- 
gravated by touch and motion. There was a tumor (for which 
she had been blistered) in the right iliac fossa, which was of 

25 385 



386 THE DISEASES OF WOMEN. 

irregular outline, and could be very plainly felt above the brim 
of the pelvis. The corresponding limb was retracted. She could 
not lie upon that side. She had diarrhoea, with black, shiny 
stools. She complained of cramps in the uterine region on going 
to stool. Burning during micturition. Emaciation. Pulse 85, and 
weak. Tongue coated. Yesterday she commenced to have a 
pretty free discharge of pus from the uterus, and her symptoms 
are already somewhat relieved. Until then the vagina was hot, 
dry and very sensitive. The tumor could be recognized by the 
" touch," located at the right side of the cervix uteri in the roof 
of the vagina. 

Synonyms. — This disease has received several names which 
only serve to confuse the mind. Thus, among its synonyms are 
pelvic cellulitis, peri-uterine cellulitis, perimetritis, parametritis, 
pelvic abscess, intra-pelvic abscess, abscess of the uterus, inflamma- 
tion and abscess of the broad ligaments. The term peri-uterine 
cellulitis, proposed by Dr. Thomas, as locating the lesion more 
definitely, and implying that this is one of the sequelae of uterine 
disease or accident, is perhaps least objectionable. 

You are aware that the pelvis is lined with a fascia which is re- 
flected over the muscles contained within it, and over the pelvic 
organs also, and which serves 'to shield, to 

The pelvic cellular tissue. 

• strengthen and to separate them. .Now be- 
tween the layers of this pelvic fascia, when they come into con- 
tact with each other, and also between the fascia and the organ 
which it covers or separates from another organ, there is inter- 
posed a quantity of loose cellular tissue. This tissue is particu- 
larly abundant between the folds of the broad ligaments, about 
the abdominal portion of the uterine cervix, between the uterus and 
the bladder, about the urethra, in the recto-vaginal septum, and in 
the recto-sacral space. There is considerable discrepancy among 
authors concerning the presence of this areolar tissue between 
the peritoneum and the Uterus itself, a majority insisting that 
there is so little of it there as scarcely to be worth mentioning. 
Hence there are those physicians who insist that peri-uterine cel- 
lulitis proper is a kind of mythical disorder — one of the refine- 
ments of uterine diagnosis. 

But I apprehend that there is no real conflict between the au- 
thority of the anatomist on this point, and the experience of the 
gynaecologist, when he finds that attacks of inflammation are 



PELVIC CELLULITIS. 387 

sometimes seated in the areolar tissue about the uterus. For this 
form of the disease is especially incident to the 

An important suggestion. a i i i ,i 

puerperal state. And when we remember the 
changes that take place in the other uterine textures in conse- 
quence of conception, I can see no reason to doubt that there is, 
during pregnancy, a corresponding growth and development of its 
cellular tissue also. Authors have not, in so far as I am aware, 
said anything on this subject. Nevertheless it may be true that 
this particular tissue, like the muscular coat of the womb, is pro- 
duced and then removed to answer certain very important physi- 
ological ends ; and that this consecutive development and decline 
constitute a predisposing cause of cellulitis as one of the con- 
tingents of labor, whether premature or at term. At any rate, I 
give you the hint as one that contains something practical. 

Peri-uterine cellulitis, therefore, is an inflammation of the con- 
nective tissue about the uterus and within the pelvis. As I have 

said, when it is not traumatic, it rarely occurs 

Frequency of. . 

except as a sequel or contingent ot lymg-m. 
Gestation and labor are, therefore, its most powerful predispo- 
nents. The disease is less frequent than puerperal peritonitis 
and phlebitis, but is probably more common than many practi- 
tioners have supposed. (Exit the 'patient.) 

Authors divide this disease into three, but I shall specify four 
stages. The first is that of congestion, the second of effusion, the 

third of absorption or resolution, and the fourth 

Its four stages. . _ 

ot suppuration. I add the stage oi resolution, 
because I believe that appropriate treatment will sometimes en- 
able us to cure our patients without allowing the disease to pass 
on to the suppurative stage. 

The First or Congestive Stage. — The congestion may set in ab- 
ruptly a few hours after delivery, or it may be delayed until some 
days or even Aveeks have passed, and then may 
come on insidiously. The symptoms are such 
as mark the onset of inflammatory fever. There is a more or less 
decided chill, which may or may not be repeated. If the chill is 
lacking, it will be substituted by rigors, which are sometimes 
painful and persistent in ratio with the exhausted and debilitated, 
condition of the patient. The febrile re-action is very decided. 
The heat of the skin is often intense, the pulse full, strong and 



388 THE DISEASES OF WOMEN. 

rapid, or, in weak subjects, quick, frequent and irritable. The 
tongue is furred, and not unfrequently there is nausea with dispo- 
sition to emesis. 

These symptoms are accompanied, or followed almost immedi- 
ately, hy intra-pelvic pain and distress. The location of this pain 
varies with the seat of the inflammation. If 

Intra-pelvic pain. . ' -, \. 

the cellular tissue between the broad ligaments 
is attacked, the pain will be referred to the corresponding side of 
the pelvis, in which it will be deep-seated and very severe. If the 
same tissue surrounding the uterine neck is the seat of the lesion, 
the suffering will be in the upper part of the vagina, and contact 
with this organ, even by the exercise of the most delicate " touch," 
will be insupportable. If the peritoneum is also inflamed, the 
pain will be acute and lancinating in character. Most of the pain 
experienced, however, is ascribed to the pressure of the effused 
fluid (which has escaped into this tissue) against the neighboring 
organs. In many cases the bladder, and in others the rectum, are 
thus mechanically pressed upon, giving rise to strangury and 
tenesmus, which are not relieved by the usual remedies. Very 
often, more especially after the tumor caused by the effused serum 
has been formed, the pain is described as throbbing and paroxys- 
mal. It is usually not diffuse, but local and circumscribed in its 
extent. In acute cases the congestive stage is limited to a few 
hours. 

The Second or Stage of Effusion. — As in peritonitis or pleu- 
risy, the period of effusion generally follows in pretty rapid suc- 
cession. The serum escapes from the capilla- 

Formation of the tumor. ... - , pi i r> l 

ries into the meshes of the areolar tissue, infil- 
trates it, and solidifies as if it were out of the body, or just as it 
does in the pulmonary air-cells when it causes a hepatized state 
of the lung in pneumonia. The resulting tumor varies in it'< 
shape and size according to circumstances. If the space between 
the fasciae is limited and of a particular shape, the " swelling ,f 
cannot be larger, and must be of the same configuration. It 
grows rapidly until it has attained its maximum size, becoming 
more and more firm and dense, or perhaps softer, in its structure. 
If the patient is in a weak, adynamic state, however, the clot will 
not be firm, and the tumor will remain flaccid, or become softer,. 
in some such manner as it does in pelvic heematocele. In many 



PELVIC CELLULITIS. 389 

examples the tumor is exquisitely tender to the touch, but again 
it is not so. 

In the majority of cases of peri-uterine cellulitis, the tumefac- 
tion is situated in the lateral portion of the pelvis. You may find 
it in one or the other of the iliac regions. And 

Location of. . . _ 

its presence is best made out by means ot the 
bi-manual exploration. The index finger of the right hand being 
introduced into the vagina for the purpose of examining the os and 
cervix uteri, as well as the cul-de-sac of Douglas, the iliac 
region is examined at the same time through the abdominal pari- 
etes with the other hand. Between the two the size, shape and 
consistence of the tumor, whether it be above the pelvic brim or 
below it, can be pretty accurately determined. If there are any 
remaining doubts, the finger may be introduced into the rectum, 
and so much of the posterior and lateral walls of the womb as are 
within reach may also be examined. As a rule the uterus is fixed, 
or but sliqiitlv movable. 

One of the first symptoms indicative of this effusion is a local 
heat, swelling and tenderness of the vagina, which is apt to be 

felt at one side of the canal, and limited to one 

Symptoms. . . 

spot. Later the vaginal wall covering the tumor 
becomes thickened and indurated. It may, or may not, remain 
sensitive. 

If the tumor develops in either iliac fossa, the corresponding 
limb will usually, but not always, be flexed. This retraction of 
the thigh relieves the pain by relaxing the muscles in the imme- 
diate vicinity of the tumor. It is involuntary, and more or less 
complaint will be made when the leg is distended. 

In jmerperal women the milk and lochia are usually suppressed. 

This complicates the case, and implicates the nervous system more 

especiallv. Delirium, insomnia, unrest, spasms, 

Incidental symptoms. l . 

convulsions, and even mama have followed irom 
this cause. In rarer cases there is retention of urine, and still 
more rarely an almost total suppression thereof. Vomiting is a 
frequent accompaniment of pelvic cellulitis, possibly, as Dr. Att- 
hill suggests, because of the endo-metritis which generally co- 
exists. 

This stage of effusion, with its resulting tumor, may continue 
unchanged for a variable period ranging from one week to a 



390 THE DISEASES OF WOMENo 

month. There is no fixed limit to its duration. Sometimes, in con^ 
sequence of a relapse, the congestion is again 
established, and the resulting effusion follow- 
ing, there is an increased pouring out of serum and a marked and 
sudden growth of the tumor. Again the inflammation being pas- 
sive, the tumor becomes insensibly larger. Or it may develop in 
the right iliac fossa, and when some considerable time has elapsed, 
commence to grow and finally attain a marked development in the 
left one. Successive tumors of this kind occurring in the same 
locality, are by no means rare. 

The Third Stage, or that of Resolution. — The stage of absorp- 
tion, or of resolution, is that in which the tumor- may remain for 
some time at a stand-still, and finally pass away 
without ending in suppuration. As you will 
infer, if for any reason, as for example because of a depraved 
cachexia, great debility from previous illness, inanition or excessive 
medication, the patients' vitality is very much reduced, the reso- 
lution of the swelling would be impossible, and suppuration would 
almost inevitably follow. Under the circumstances, therefore, in 
which we are likely to find these patients, this third stage of the 
disease will frequently be lacking altogether. 

But when her strength has previously been good, her gestation 
and labor have been accomplished without too great a draught 
upon her nutritive and nervous resources ; 
res C o?;'t d ion? nsthatprom ° te when she has been well nursed and properly 
fed, medicated and otherwise cared for; and 
above all when there is no prevalent epidemic erysipelas, or puer- 
peral disorder, we may observe the tumor gradually and quietly 
resolving itself away under appropriate treatment. If the swell- 
ing consists of effused serum, and not of coagulable lymph, it 
may be more readily absorbed. 

The Fourth, or Suppurative Stage. — If left to itself, however, 

or mal-treated, and in a majority of cases almost inevitably, the 

tendency of this disease is to terminate in suppu- 

Symptoms of. . „ . 

ration. With the commencement 01 this pro- 
cess the symptoms vary as in the case of abscesses located else- 
where. If the pain and tenderness have subsided, they are very- 
apt to return. The tumor may become extremely sensitive again, 
and motion, or the pressure upon the tumor caused by an attempt 



PFXVIC CELLULITIS. . 391 

to stand upon the feet, to urinate, or while at stool, may occasion 

extreme suffering. The limb cannot be extended. The patient's 

body is flexed in the bed. A species of hectic 

Accompanying hectic. 

lever, 01 a remittent type, sets in. there are 
rigors alternating with great heat, and evening exacerbations of 
fever, which sometimes mislead the physician. When she sleeps 
there is a profuse and exhausting perspiration, as in the worst 
cases of phthisis. The face and skin are pale. The countenance 
assumes the expression which surgeons recognize as characterizing 
that pus has been formed somewhere in the body, and is awaiting 
its discharge. The pulse continues rapid, although it has lost in 
strength. There is anorexia and great debility, with or without 
diarrhoea. 

Even although the tumor may have been firm and like fibro- 
cartilage, or almost like scirrhus, to the touch, it now begins to 

soften. This softening may be recognized either 

Seat of the fluctuation. ,,-,.-, P , , . , 

by abdominal or vaginal palpation, or by both 
combined. It may occur gradually, or develop itself more rapidly. 
The weaker the patient the less the resistance to this process, and the 
more speedy the resulting fluctuation. This fluctuation is in most 
cases observable at the upper part of the vagina at one side of, or 
directly behind the cervix uteri, in the posterior cul-de-sac. 
" From some peculiar arrangement of the layers of the pelvic fas- 
ciae, when pus is formed in the course of a pelvic cellulitis, occur- 
ring in the upper half of the true cavity of the pelvis — and this, 
you must remember, is the most frequent seat of the disease — it 
has a tendency always to point in this direction and to find an exit 
for itself, either at the lower base of the broad ligaments, or in 
the posterior cul-de-sac of the vault of the vagina ; and it is at 
these spots, where the fascial layer seems to be unusually thin and 
weak, that the feeling of fluctuation is ordinarily first detected."* 
Now this fluctuation may be due to the presence of effused 
liquor sanguinis, or of pus. But if the disease has persisted, as 

in the case before us, for a considerable time, 
gnosis of the presence and been attended by the inflammatory fever, 

followed by the hectic, the copious perspiration 
after sleeping, and the frequent, irritable pulse, you may be rea- 
sonably assured of the presence of pus in the tumor. 

^Clinical Lectures on the Diseases of Women, by Sir J. Y. Simpson. D. Appleton 
& Co., New York, 1872, page 72. 



392 THE DISEASES OF WOMEN. 

Concerning the means of escape for the pus, when it has been 

formed, it is important to remember that it may extemporize an 

outlet for itself through the bladder, the uterus, 

Its varied means of escape. . . 

the vagina, or the rectum, It it iorms at the 
superior strait, it may gravitate, and, running down along the 
course of the muscles, may pass beneath the pelvic fasciae, and 
escape with the femoral vessels, so as to point near the groin. 
Sometimes it passes backwards through the great ischiatic fora- 
men, and forms an abscess in the region of the hip ; or it may 
even point at the great trochanter of the thigh bone. In rare 
instances it perforates both the uterus and the bladder, and leaves 
a fistula between them. Still more rarely, perhaps, it discharges 
into the cavity of the peritoneum. In seventy cases of puerperal 
pelvic cellulitis, Dr. McClintock, of Dublin,* found that thirty- 
seven ended with suppuration and the discharge of pus. Of these 
twenty-four were opened externally, or burst, of which twenty 
were discharged from the iliac region, two above the pubis, one 
in the inguinal region, and one beside the anus. Six others found 
an outlet through the vagina, five through the anus, and two 
burst into the bladder. 

With respect to the essential nature of this disorder, I have 
long held and taught the idea set forth by Virchow, that, in reality, 
it is a species of erysipelas. Its clinical history, 
cenuHti 1 s t . ialnatureofpelvic its epidemic prevalence, and its special thera- 
peutics, correspond with those . of erysipelas, 
more closely than with any other disorder. It is quite probable 
that many cases of this disease have been mistaken for puerperal 
peritonitis, and that the propagation of this latter malady by cer- 
tain fomites is really to be explained upon the 
siplifs. ^ 1 ^ 11 ^ 10 ^" theory of the inoculability of the erysipelatous 
poison as in the case of phlegmonous erysipelas. 
Causes. — I have already reminded you that pelvic cellulitis is 
one of the contingencies of lying-in. It may follow in conse- 
quence of injuries sustained in natural unassist- 
ed labor. One of its most frequent causes is 
the traumatic injury of the cervix uteri by pressure of the pre- 
senting part, especially of the head, during delivery. In abortion 

* Clinical Memoirs on the Diseases of Women. 



PELVIC CELLULITIS. 393 

it may follow a similar injury to the neck of the womb. For this 
reason it is comparatively frequent where abortion has been in- 
duced by means that are almost necessarily harmful. Women 
have sometimes brought it on themselves in this way. 

Puerpesul cellulitis is one of the sequelae of instrumental deliv- 
ery, more especially when the resort to the forceps and other in- 
struments has been unwarrantably delayed, 

A sequel to dystocia. 

when they have been ignorantly or carelessly 
used, and when the patient has not received the proper attention 
and nursing after their employment. These causes are more effi- 
cient in proportion with the debilitated and depraved condition 
of the patient's system, and also with her proneness to scrofulosis, 
phthisis, and even to certain acute diseases, as, for example, pneu- 
monia and erysipelas. 

The non-puerperal cellulitis may result from the forcible intro- 
duction, or the prolonged retention, of the sound and the 

sponge or other tents. The wearing of intra- 
su4er y ntingentofuterine uterine pessaries, even the best of them, 

is very apt to induce it. Incision of the 
cervix uteri, whether for the cure of obstructive dysmen- 
orrhcea, for the removal or arrest of development of fibroids, 
or even for the arrest of uterine haemorrhage, is not an in- 
frequent cause. It has followed amputation of the cervix, 
ovariotomy, the ligation of polypi, the excision of haemorr- 
hoidal tumors, the operation for vesico- and recto-vaginal fistulae, 
and also that for ruptured perineum. It has also resulted from 
the use of very severe escharotics, as the potassa cum calce ; the 
wearing of vaginal pessaries for a long time without removal ; 
excessive and too forcible coitus ; and the extension of corporeal 
metritis and ovaritis to the areolar tissue about the uterus, and 
between the layers of the broad ligaments. 

Coincident Diseases. — Peri-uterine cellulitis rarely runs its 
whole course without being more or less complicated with other 
diseases. This is true, indeed, of most of the ailments for which 
you will be called upon to prescribe. The lines that separate 
pneumonia from pleurisy, or rheumatism from neuralgia, for ex- 
ample, are much more distinct and clear in the books than you 
will find them to be at the bedside. So you will most frequently 
observe that this form of cellulitis is more or less confounded with 



394 THE DISEASES OF WOMEN. 

pelvi-peritonitis, ovaritis, and endometritis, in which case its clini- 
cal history and symptoms will be modified accordingly. 

Diagnosis. — This fact complicates its diagnosis. If you are not 
more skillful than your predecessors, you will sometimes be puz- 
zled to differentiate between pelvic peritonitis, 

Sometimes very difficult. \ • ■ -i i • r»i n • 

pelvic neemotocele, uterine fibroids and pelvic 
cellulitis. Let me beg your earnest attention therefore, while I 
tell you how you may know them apart. 

The pelvic areolar tissue being between the layers of the broad 
ligaments, and beneath the outer coat of the uterus, both of which 

structures are composed of reflections of peri- 

From pelvi-peritonitis. . 

toneum, it may be supposed that in case 01 in- 
flammation of either of them, the symptoms must necessarily be 
very distinct, not to say pathognomonic, in order to be recognized. 
As a rule, the pain in the first stage, prior to effusion, is less acute 
in cellulitis than in pelvi-peritonitis. In the former, if the exu- 
dation of the liquor sanguinis is copious, the suffering is increased 
by it ; while in the latter, as in pleurisy or synovitis, the effusion 
is followed by a mitigation, if not by an entire remission of pain ; 
which may return, but which, from that time forward, is less, 
acute and altogether changed in its character. 

In most cases of cellulitis the tenderness, pain and local heat 
are referred to and commence in the iliac fossse. The same is true 
of puerperal ovaritis, in which the peritoneal investment of the 
ovary becomes inflamed during lying-in. But in the former the 
pain does not change its location, nor does it incline to become 
diffused over the abdomen, both of which symptoms are proper to 
ovaritis occurring in puerperal women. 

I have copied Dr. Thomas' table, giving the differential signs, 
between peri-uterine cellulitis and pelvi-peritonitis, upon the 
blackboard :* 

PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 

1. Tumor easily reached, generally found I. Tumor, if discoverable, very high, only 

to one side of the uterus, and may be in vaginal cul-de-sac, does not extend 

felt above the pelvic brim ; above the superior strait ; 

2. Tendency to suppuration ; 2. Suppuration less common ; 

3. Abdominal tenderness chiefly over one 3. Abdominal tenderness excessive above 

iliac fossa ; brim of the pelvis ; 

* A Practical Treatise on the Diseases of Women. By T. Gaillard Thomas, M.D., 
~tc. Third edition, 1872, page 461. 



PELVIC CELLULITIS. 395 

PERI-UTERINE CELLULITIS. PELVIC PERITONITIS. 

4. Tumefaction generally noticed later- 4. Generally noticed near or upon the 

ally in the pelvis ; median line ; 

5. Tendency to monthly relapses not 5. Tendency to relapse every month 
marked ; very marked ; 

6. Retraction of thigh not rare ; 6. Retraction of thigh rarely occurs ■ 

7. Pain severe and steady ; 7. Pain excessive and often paroxysmal ; 

8. Facies not much altered ; 8. Facies very anxious ; 

9. Nausea and vomiting not excessive ; 9. Nausea and vomiting often excessive ; 

10. Does not necessarily displace the 10. Displaces the uterus as a rule ; 
uterus ; 

11. Uterus fixed to a limited extent ; 11. Uterus immovable on all sides. 

The statement of some of these signs needs to be qualified. If r 
for example, the inflammation in cellulitis was always limited to 
the broad ligament on either side, the tumor could invariably be 
reached without difficulty by downward pressure in the corre- 
sponding iliac fossa. But the fact is that it has no such constant 
seat. It may happen that the connective tissue surrounding the 
inferior segment of the womb, or about the cervix uteri, shall be 
inflamed, while that which separates the layers of the broad liga- 
ment escapes altogether. In this case we should fail to find the 
tumor at the superior strait, but might detect it per vaginam or 
by the rectum. In exceptional instances of pelvic cellulitis, it is 
impossible to locate the tumor at all. 

Peritonitis is more directly related to disorders of menstruation, 
and to the return of the monthly cycle, than cellulitis. The com- 
mencement and brief continuance of the peritoneal pain in the 
median line, and the absence of a marked tendency to suppura- 
tion, will generally enable you to separate this disease from pelvic 
cellulitis. Owing; to the extension of the inflammation in this 
form of peritonitis, the induration, if there is any, is not always 
located in the median line, as the pain was at the beginning of the 
attack. When gonorrhoea! , or, indeed, ordinary inflammation, ex- 
tends from the uterine cavity through the Fallopian tubes, and 
invades the abdomen and the pelvis, it is more likely to give rise 
to peritonitis than to cellulitis. You should not forget that, while 
pelvi-peritonitis is quite a common affection with non-puerperal 
women, pelvic cellulitis almost never occurs excepting among 
those who have recently been confined. 

It must be acknowledged, however, that the lines which sepa- 



396 THE DISEASES OF WOMEN. 

rate these two diseases are not always distinct. For, whether \t 
be due to the fact that the textures involved 

They may co-exist. . 

are contiguous, and that these lesions frequently 
co-exist, or that our present means of differentiation are imper- 
fect, it remains that they may be combined without our knowing 
it, and that we are liable occasionally to mistake one for the other. 
Although pelvic cellulitis and pelvic hematocele are both of 
them most frequent after delivery, yet the conditions of the 
patient's general system upon which they are 

From pelvic hematocele. too rrn i • 

prone to occur are very different. Ihus, pelvic 
hematocele takes place in consequence of a weak, adynamic state 
in which the blood has become of bad quality by extreme losses, 
as in uterine hemorrhage, or from the rupture of one or more 
small vessels during labor. It is also incident to the hemorrhagic 
diathesis. Neither of these conditions pertain to the etiology of 
pelvic cellulitis. 

In pelvic hematocele the formation of the tumor is not pre- 
ceded by local congestion, and symptoms proper to the first stage 
of an acute inflammation, as in cellulitis. It comes on suddenly, 
and is accompanied by signs of prostration, sinking, and collapse. 
The tumor in hematocele varies in its consistence, but is never 
hard and ligneous to the feel, like that of cellulitis. The more 
impoverished the blood, the softer the tumor. In cellulitis, the 
tendency toward suppuration causes the swelling to become softer 
as it grows older. The opposite change occurs in the hemato- 
matous tumor, which gradually becomes harder than it was orig- 
inally. 

Uterine fibroids come on insidiously and grow very slowly. Un- 
til they occasion trouble mechanically they are neither sensitive 
nor do they cause pain in the womb or the adja- 

From uterine fibroids. . . . 

cent parts. If sub-mucous, or interstitial, they 
are characterized by the frequent occurrence of metrorrhagia, and 
inter-periodic hemorrhage, which is not a contingent of cellulitis. 
The tumor, in case of fibroid, is firm and not oedematous to the 
feel, and there is no tendency in it toward suppuration. Fibroids 
do not render the uterus immovable, as the tumor in cellulitis 
-often does. 

In case, however, that you can not otherwise decide as to the 
nature of the pelvic tumor, you may pass the exploring-needle into 



PELVIC CELLULITIS. 397 

it from its vaginal surface. If you bring away a drop or two oX 
pus upon the instrument, it is a positive sign of abscess ; if blood 
only, and that of a dark, purplish color, it may be a case of hem- 
atocele ; and if no specimen of any kind of abnormal product is 
obtained, the negative symptom will satisfy you that it is probably 
a case of uterine fibroid. This is an excellent means of diagnosis 
and may really be a great blessing in your hands. For the safety 
of your patient, as well as of your own reputation, will depend 
upon your skill in diagnosis. 

Sequelae. — The most common sequel of this form of cellulitis is 

pelvic abscess. It often happens that the evacuation of the tumor 

a single time will not suffice. In many cases 

Relapsing abscess. . 

these abscesses continue to discharge lor months 
and even for years. The accompanying symptoms vary with the 
location of the tumor and its means of outlet. Incredible quan- 
tities of pus are poured out, and the patient's strength and vitality 
are so undermined that her health may be ruined thereby. 

Another result of this disease, which is frequently entailed 
upon those who have had it, is sterility. It is not unusual for a 

woman to lose her first-born in consequence of 

a difficult labor, to have cellulitis in child-bed, 
and to recover her health in every respect, except that in future 
she remains barren. In this case the cellular inflammation has 
caused the function of reproduction to be suspended. This fre- 
quently happens as an indirect result of criminal abortion. 

Menstruation is sometimes most seriously implicated, either 

because of ovarian complications, with cellulitis, 

Menstrual disorders. . 

or from some partial or complete obstruction or 
the Fallopian tube or of the cervix uteri. 

Other sequelae include certain uterine displacements, and the 
vesico- or recto-vaginal fistulas which are sometimes caused by 
sloughing of the septa between the bladder, or the bowels and 
the vagina. 

Prognosis. — The prognosis should be cautiously made. If it is 
possible to secure the resolution of the tumor, and to prevent seri- 
ous relapses, the patient will probably recover.. 
concurfenrdlease ditior and Mucn w ^ depend, however, upon the general 
strength and vitality. If these shall be very 
much reduced, the case is less promising. So also with the 



398 THE DISEASES OF WOMEN. 

chronic and incurable disorders of digestion with which it may be 
complicated. But you should not despair of curing even the 
worst attack, provided the patient is not already moribund, and 
you can supply certain physiological requisites for her recovery. 
If the disease is epidemic, the prospects are less favorable. If 
it occurs in the winter or spring months, during stormy and in- 
clement weather, when erysipelas, diphtheria, 

The epidemic tendency. . .. 1 _ . 1 

scarlatina, or dysentery, and kindred diseases 
are prevalent, it subtracts so much from the chances of recovery. 
Those cases which arise from traumatic injury are generally more 
grave than such as are referable to more ordinary causes. 

If the disease invades other organs, as when the pus that has 
formed finds an outlet through the uterus or the bladder, it may 
prove fatal through the serious complications that follow. If the 
abscess discharges into the cavity of the abdomen; the patient will 
be -very apt to die suddenly. 

The janitor's bell, which is as inevitable as one's shadow, has 
overtaken us. I will speak of the treatment of pelvic cellulitis at 
my next lecture. 



LECTURE XXV 

PELVIC CELLULITIS. (CONTINUED.) 

Pelvic cellulitis, continued ; Prognosis. Case; the Sequelae and Treatment. Case. 

Case. — Mrs. , is married, and the mother of two chiU 

dren, both of whom are dead. She had an abortion at the thrid 
month, now six months ago, and has not been well since. For 
many years she has been subject to leucorrhcea, and while an 
inmate of St. Luke's Hospital, in New York, she says she had 
blisters applied to the region ot the ovaries for the cure of that 
infirmity. The menses are copious, returning every three weeks, 
and continuing for from four to six days. 

A local examination in the sub-class room revealed great tender- 
ness in the ovarian and pubic regions, the cervix was somewhat 
swollen, and about the os uteri it was highly inflamed. In the left 
lateral cul-de-sac, the finger detected a placque of inflamed areolar 
tissue which has been the seat of an extensive infiltration, and 
which has doubtless existed for a long time. There was no lacera- 
tion of the cervix uteri. 

Next to the differential diagnosis of this disease, its prognosis is 

the most difficult and imperfect. In a given case the result will 

vary with the cause, the complicating lesions, 

Qualifying conditions, " ° 

the condition 01 the menstrual function, the 
treatment to which the patient has formerly been subjected, her 
puerperal experience, and the clyscrasia upon which the cellulitis 
has been engrafted. 

1. The cause. — Cases which date from the lying-in, and which 
have developed from injuries received during labor, are very tedi- 
ous and difficult of cure. Puerperal traumatism 

Traumatic causes. . „ . , . . 

is a fertile source of pyemic relapsing pelvic 
abscess, especially if the mother has failed to nurse her infant, is 
of the scrofulous or tuberculous habit, or has not been properly 
cared for in child-bed. 

Other forms of peri-uterine traumatism resulting from surgical 
operations about and within the cervix uteri, the wearing of ill- 
adjusted pessaries, inveterate constipation, the pressure of uterine 

399 



400 THE DISEASES OF WOMEN. 

fibroids, stone in the bladder, and sexual abuse, are followed by 
forms of cellulitis which are severe and dangerous in proportion 
with the acuteness of the attack, the nature and more or less con- 
stant action of the exciting cause, and the physical ability of the 
patient to survive the effects. 

In miasmatic districts, and in tropical climates, where bilious 

disorders abound, there are cases of pelvic cellulitis that depend 

indirectly upon a derangement of the portal 

In paludal districts. . . l , . . 

circulation. VV nile the hemorrhoidal and the 
ovarian veins are gorged with blood from this cause, a cure of the 
concurrent cellulitis is not to be expected. Some of these cases 
will get well merely from a change of climate. 

Certain epidemic causes affecting women in child-bed, leave their 
impress upon this form of post-puerperal inflammation. If a 

woman has had either erysipelas or scarlatina,, 

In epidemics. 

peritonitis or phlebitis, septicemia or pyaemia 
during the lying-in, an inflammation of the pelvic areolar tissue 
that may be engrafted upon her, will partake of its characteristics, 
and the prognosis will vary accordingly. 

2. The complicating lesions. — The most important of these are 
pelvic peritonitis, hematocele, hemorrhoids, uterine fibroids, 
ovaritis, cystitis, urethritis, vaginitis, laceration and ulceration of 
the cervix uteri, ulceration of the rectum, chronic metritis and 
uremia. 

Peritonitis holds about the same relation to cellulitis that 

pleurisy does to pneumonia. Either may precede the other in the 

order of its coming, but they often and indeed 

With peritonitis. , , . A ° T . lT: , 

usually co-exist. In a serious case, therefore, 
this fact should be borne in mind, for without it a careful prog- 
nosis would be impossible. The suppurative form of peritonitis, 
especially if it is of pyemic origin, is a serious and dangerous com- 
plication of pelvic cellulitis. If, however, it sets in, in the puer- 
peral state, when more than a fortnight has elapsed since the birth 
of the child, it is likely to run a tedious course and finally to 
terminate in /eoovery. Tubercular peritonitis is a complication 
that is necessarily of a fatal character. 

If the peritonitis is ovarian, the lesion will be apt to develop into 
an abscess, that may discharge itself through the Fallopian tube, 
or the rectum, or possibility through the abdominal parietes, or 



PELVIO CELLULITIS. 401 

there will almost certainly be a resulting disorder of menstruation 
of an intractable kind. 

The complication of peritonitis with cellulitis is less likely to be 
rapidly fatal than to become chronic, and is exceedingly trouble- 
some on account of the persisting lesion of 
Anew version of an structure or of f imct ion, in either or all of the 

old fact. ' m ' 

pelvic organs. This is the root and the founda- 
tion of the uterine cachexia. It is as true now as it was fifteen 
years ago, when Bernutz, in speaking of pelvic peritonitis, insisted 
that " the future knowledge of uterine pathology is as certainly 
subordinate to an acquaintance with this affection as pulmonary 
pathology is to a complete knowledge of inflammation of the 
thoracic serkms membrane." Dr. Emmet's recent observations 
confirm this remarkable exhibition of clinical foresight. For 
Bernutz really suggested what Emmet has just now developed. 

When pelvic cellulitis, or peri-uterine inflammation of the cel- 
lular tissue co-exists with laceration of the cervix, the cure will 
be difficult. For an operation for the radical cure of the lacera- 
tion of the cervix is contra-indicated while the cellulitis remains; 
and the cellulitis is not likely to be cured while fhe laceration 
remains. 

3. The condition of the menstrual function. — Whether we con- 
sider the menstrual function as eliminative or not, there is a causa- 
tive relation between the arrest of the menses, 

Menstrual disorders n < • i ;i vj. r ^i 

and cellulitis. as we ^ as cer tam changes in the quality of the 

discharge, and the occurrence of a severe type of 
pelvic cellulitis. Experience teaches that, when the monthly 
derangement precedes the local cellulitis, the case is amenable to 
treatment directed against the first cause of the attack, but not 
otherwise. 

If the disease began with the resumption of the menses at the 
close of lactation, i't will be very apt to develop into abscess of the 
broad ligament, and to be rebellious in its character. So also, if 
it follows the abrupt and premature weaning of the child from any 
cause, and the consequent reflux of the blood towards the pelvic 
viscera. I am satisfied that the resumption of the inhibited process 
of ovulation is a very important factor and complication of this 
disease in those who have borne children. In a certain proportion 



402 THE DISEASES OF WOMEN. 

of cases of pelvic cellulitis we cannot foretell the result without 
weighing these conditions very carefully. 

Pelvic cellulitis is sometimes complicated with an intractable 
menorrhagia. There is no doubt that in many cases of so-called 
chronic metritis accompanied by copious men- 
luiitis. "^ 1 ^ aad Cel " struation, the lesion is really one of peri-uterine 
cellulitis. In this class of cases the prognosis 
will hinge upon our ability to control and to cure the excessive 
flow. But we must not forget that these conditions predispose 
our patients to pelvic hamiatocele, and also to concurrent peri- 
tonitis, under which circumstances the danger is very much in- 
creased. 

4. The treatment to which the patient has formerly been sub- 
jected. — A very considerable proportion of the cases of pelvic cellu- 
litis that come to us for advice, have already been 
ment. ChieVCUS treat " cauterized or maltreated in one way or another. 
Sometimes we know what escharotics have been 
employed, and sometimes not. Occasionally the patient is able to 
give an intelligent account of operations that have been made upon 
the cervix uteri, and of expedients that have been resorted to for 
the dilatation of its canal, to change its direction, or to correct some 
special form of uterine deviations. But oftener she is in the dark 
about the whole business, and we are left to conjecture what may 
have been done, frcm the traces of mischief that remain behind. 

If we know what the peculiar practice of her former physician 

is, or is very likely to have been, we shall have the key to the case, 

or at least to its complications. This informa- 

A clinical hint. #11 n . ^ 

tion will come to us from various sources, ror 
example* in my own practice, having cases that come from all 
quarters, I have found it necessary to know, through all the books 
and journals that I can get, just what form of practice is most 
popular with each and all of our uterine specialists. So that, when 
a patient comes to me from a prominent gynaecologist in New 
York, or Philadelphia, or San Francisco, or from some of my 
neighbors nearer home, my knowledge of their writings, of the 
work they do, and of their way of doing it, is useful in putting me 
on my guard, both as to the prognosis and the treatment of pelvic 
cellulitis and its complications. For these post-gynaecological 
lesions are not always of a trifling or a transient character ; and 



PELVIC CELLULITIS. 403 

if we promise to cure the cases upon which ^hey are secondary, 
as we might reasonably do if they were idiopathic, we shall often 
fail. 

If we remember that there is not a single method of surgical 
treatment for uterine affections, from the adjustment of a pessary 
to the operation for laceration of the cervix, which is not capable 
of causing pelvic cellulitis, or peritonitis, or both of these affec- 
tions, and that most frequently they are resorted to by physicians, 
and often by specialists, in an indiscriminate manner, we shall not 
be, likely to forget that the prognosis will depend upon what has 
been done for these cases before they came into our hands. 

5. Her puerperal experience. — The form of pelvic cellulitis 
which results in abscess of the broad ligament, is often of an insid- 
ious kind, and may continue for months or years without being 
suspected or discovered. It is usually the result of pyaemia, and 
may be complicated with lacerations of the soft parts, that have 
healed spontaneously, or others that remain, and which can be 
found upon a very careful inspection. When 

Post-puerperal lesions. , uiir^-i 

these traumatic lacerations have healed of them- 
selves and disappeared altogether, and when the patient is unable 
to give any detailed information concerning her lying-in, it is very 
difficult to make a careful and reliable prognosis. This is a clinical 
fact which can be verified in our daily experience, and which fur- 
nishes an argument for the necessity of a better knowledge of the 
puerperal diseases. 

When abscess of the broad ligament (which depends upon an 
inflammation of the cellular tissue between the layers of that liga- 
ment), becomes chronic, and relapses frequently, 
broad\gament° f the ^ * s a ^ mos t always complicated with some seri- 
ous disorder of the menstrual function. Not 
infrequently the latter furnishes the best criterion of the gravity of 
the disease, and also the best guide to its treatment. In very 
exceptional cases this form of abscess, with its periodical discharge, 
is vicarious of menstruation. There is a class of cases of pelvic 
cellulitis that occur in women who have borne their children 
rapidly, who have had but very indifferent attention during their 
lying-in, and who suffer from it because the parts that are chiefly 
concerned, more especially the cellular tissue, have not recovered 
from the effects of one pregnancy before they are precipitated into 



404 THE DISEASES OF WOMEN. 

those of another. Under these circumstances, the patient's general 
strength is so reduced, and the vitality of the intra-pelvic tissues 
has become so low that the prognosis, in so far, at least, as a radi- 
cal cure is concerned, will need to be qualified. For this state of 
things borders upon the uterine cachexia, and is not always cur- 
able. 

Another form of post-puerperal cellulitis is at the bottom of 

certain chronic affections of the bladder and urethra. The lesion 

is a legacy of the puerperal state. It is peri- 

With vesical lesions. . \ . 

cystic, and very intractable. In some cases, it 
has been caused by the use of an unclean catheter during the lyino-- 
in; in others, by a careless neglect in allowing the urine to 
accumulate inordinately, in cases of peritonitis or endo-metritis 
when, after having urinated naturally for some days, the patient 
loses the power to do so. The prognosis in these cases is very 
unpromising and the greatest care and patience are necessary in 
order to bring about a favorable result. One reason for this lies 
in the fact that the local cellulitis in the vicinity of the bladder and 
of the urethra is almost certain to be complicated with a local 
peritonitis. 

6. The dyscrasia upon ivhich the cellulitis has been engrafted, 
— In those women who bear children, and who are of a scrofulous 
diathesis, there is a great proneness to inflam- 
mation of the areolar tissue, and a corresponding 
exemption from the forms of glandular inflammation to which 
other scrofulous persons are subject. This is shown in the history 
of puerperal mammitis, in which, in the great majority of cases, 
the disease is seated in the inter-lobular, and not in the glandular 
tissue. With this peculiar predisposition to cellulitis as a post- 
puerperal inheritance of this class of subjects, we find the same 
tendency to suppuration and abscess as in scrofulosis. 

The prognosis in pelvic cellulitis, in the case of those who are 
decidedly scrofulous, will, therefore vary with our ability to 
recognize and to overcome the effects of this complication. It is 
only by the greatest care that we can prevent the extension of the 
disease, its frequent relapse, and the recurrence of abscesses, which 
drain the patient's strength and drag her into an incurable cachexia, 
or even into tuberculosis. 

The cancerous diathesis develops a form of pelvic cellulitis, in 



PLLVIC CELLULITIS. 405 

which the lesion that is outside of the uterus, almost always follows 
the development of that within its body or cervix, so that a recog- 
nition of the cancer through the speculum, or by the touch, will 
enable us to decide upon the danger and sig- 
nificance of the accompanying 1 cell ulitis. When 
this order of succession is reversed, the fixation of the uterus, and 
the signs of the cancerous cachexia will clear up the case. We must 
not forget, however, that the anchorage of the uterus is as com- 
mon a result of a benign as of a malignant cellulitis. 

M. Louis, estimates that in at lea-st one-twentieth of all those 

who are the subjects of tuberculosis, the lesion is located in the 

generative organs. There is no doubt that the 

With tuberculosis. . n , m r • , i 

proportion ol women who sutler from genital 
phthisis, as compared with those who have the disease in some 
other form, is still larger. Those who die of pelvic peritonitis 
and of pelvic cellulitis in their chronic form, are almost always the 
victims of tuberculosis. 

So little has been said of this diathesis as a complication of pel- 
vic cellulitis, that the subject deserves especial mention in this con- 
nection. We are not warranted in promising a radical cure of this 
disease in women who are predisposed to phthisis, especially if they 
have borne many children, or if they have been treated for a con- 
siderable time by caustics and the local appliances of the old Bennet 
school. 

Even when tuberculosis does not develop within the pelvic cavity, 
the existence of chronic cellulitis may indirectly excite the forma- 
tion of tubercles in the lungs. We may anticipate this result in 
hereditary phthisis, more particularly if the disease had threatened 
to develop itself at puberty, and been suspended for a time, either 
by the establishment of menstruation or the occurrence of preg- 
nancy. In this case the prognosis of cellulitis, at or about the 
climacteric, would be almost necessarily of a serious character. 

Case. — At the request of my friend Dr. W. H. Woodbury, of 
this city, I recently saw a caso of pelvic cellulitis which was quite 
peculiar. The patient was attacked with cellular inflammation 
during her lying-in ; she was ill for a number of weeks when an 
abscess formed and discharged itself through the rectum. This 
discharge continued at short intervals, but, meanwhile, the lesion 
extended above the superior strait and reached half-way to the 
umbilicus, where it suppurated and a deep-seated abscess resulted. 



406 THE DISEASES OF WOMEN. 

A surgeon was called who made two unsuccessful attempts to open 
this abscess. On a third trial he brought away the pus, but left a 
wound in the intestine through which for three years past small 
quantities of faecal matter have been discharged. 

This unfortunate condition had been entailed upon the patient 
before she came into Dr. Woodbury's hands, and our consultation 
concerned the prognosis and the propriety of operating for the 
relief of the post-surgical lesion of the intestine. We concluded 
however that an operation was not advisable until the inflamed 
and suppurating areolar tissue about the wound had first been 
healed. The prognosis turned upon the patient's vigor, her 
ability to withstand the effects of the prolonged drain, and to 
overcome the tendency to induration and suppuration. The per- 
severing use of remedies, and the skilful and sensible adjustment 
of her surroundings may finally cure her, and fit her for t'he pro- 
proposed operation. 

Before I speak ot the treatment of pelvic cellulitis, the clerk ot 
my clinic will read you the notes of a private case which are given 
in the patient's own words, and which will serve to show the 
erratic course of the disease as well as the difficulty ot its diagnosis. 
The patient has entirely recovere I her health. 

Case. — I am twenty-eight years old, and was confined two years 
ago with my first and only child. ' I had enjoyed- perfect health 
during pregnancy, excepting a soreness of one of my breasts, 
which was occasioned by my own imprudence. My labor began 
at seven o'clock in the evening, and lasted until one o'clock the 
next morning, when I was delivered of a dead child. I was under 
the care of a midwife who gave me some powders, a little 
wine, and free draughts of cinnamon tea, in order to hasten the 
pains, which she thought were too slow. From ten p.m. to one 
o'clock a.m., I had one continued pain, and was finally delivered 
in the standing posture. The child which, two hours before its 
birth had been alive, was a very large one. 

For some days after delivery I lost a great deal of clotted and 
very offensive blood. I had pains low in the sides and groins 
almost immediately, and, five days afterwards was taken with a 
very severe chill, which was followed by a burning fever. The 
milk disappeared twenly-four hours later. The flow became yel- 
lowish and watery, instead of bloody. A physician was called, 
who decided that" I had puerperal fever. He prescribed medi- 
cines to control the fever, and ordered vaginal injections of water 
containing carbolic acid. At first [ seemed to improve, but in a 
few clays the pain in the sides returned. The doctor examined 
me internally (with a speculum), and said that I had ulcers on 
the neck of the womb. He burned them twice a week for about 



PELVIC CELLULITIS. 407 

six weeks with the nitrate of silver, but, before they were cured, 
I was taken one morning with severe cramps in the bowels, which 
lasted the whole day, and were followed by chills and fever. 
These cramps came every two or three days, and were very pain- 
ful. The doctor ordered paregoric, and afterwards laudanum. 

In the middle of the following May I was compelled to change 
my residence. My ride in the carriage was a very painful one, 
and in a few days I was worse than ever. I began to have a 
severe and steady pain in the left side of the bowels, low down 
(iliac region), and the doctor, after another examination, declared 
me to be threatened with an ovarian tumor and hardening of the 
left ligament. A greenish ointment was applied over the whole 
side of the abdomen, and the swelling gradually disappeared, but 
the ligament (Poupart's) has always remained hard. I took at 
that time a great deal of iron, and of the iodide of potash, con- 
tinuing it until my stomach could support it no longer. 

In the summer a diarrhoea, with straining, and a pain which 
continued after each passage, set in. This lasted for many months 
and left my bowels in a very weak state. I, however, improved 
gradually, and finally the doctor ordered me to go out of doors. 
Walking was difficult and painful. In August, while in the open 
air, I caught a severe cold, and became very sick again, with 
cramps in the stomach and bowels, vomiting and diarrhoea, with 
dreadful straining. Another physician was called in counsel, and 
I was said to be in great danger. They said I had a commencing 
peritonitis, with great swelling of the womb and general inflam- 
mation. 

The end of September came before I was able to be up again, 
but the diarrhoea and pains continued, and made me so weak and 
wretched that, in the following January, I resolved to try Homoe- 
opathy, and accordingly sent for Dr. S****. Within a month the 
diarrhoea and pain ceased entirely, my appetite returned, and I 
gained flesh and strength. I felt so much better, indeed, that I 
accepted a proposition to go to Europe. But toward the middle 
of March, I began to feel considerable pain in the right side (iliac 
region), which, until that time, had been well. These pains soon 
became so severe that I lost all rest. Nothing unnatural could 
be seen or felt in that locality. The pains were of a tearing char- 
acter, and extended from the right hip through the groin to the 
knee. All the pains which I had suffered before were as nothing 
compared with these. For six weeks I never slept without taking 
the hydrate of chloral, a very little of which sufficed. 

Dr. S. though^ my suffering was due to neuralgia, and, believ- 
ing that the sea-air would most probably cure me, advised me not 
to abandon the idea of going abroad. Consequently, although I 
had noticed two small lumps in my left groin, as they were not 



408 THE DISEASES OF WOMEN. 

painful, I paid no attention to them, and left Chicago for New 
York in the latter end of May. The journey proved very hurtful, 
the lumps increased in size, and I was compelled to take to my 
bed almost immediately after my arrival in New York. 

The first of June Dr. F***** came to see me, and after a thor- 
ough examination told me that I had no sign of ever having had 
an ovarian tumor, that the glands were swollen, that my sickness 
would be tedious, but that, with proper care, he thought I would 
recover. He did not wush to frighten me by saying that I 
already had one or more abscesses. 

The first of these abscesses was opened by the doctor on the 
eighth day of June, and the second a week later. Even after they 
were discharged, moving in the bed was very difficult, and walk- 
ing quite impossible. The flow of pus continued profusely for 
about a month, and, having given up the proposed voyage, I was 
not well enough to return to Chicago until the twelfth day of 
July. Dr. F. feared lest the journey by rail might determine an- 
other abscess, but it did not seem to do as much harm as it had 
done before. 

Arrived at home, I placed myself under the care of Dr. R. 
Ludlam, and although I still suffered severely at times, I was able 
to get up and to sit in an arm-chair before the fire. Walking was 
still difficult, and I abstained from it. The Great Fire came early 
in October, my house was burned up, and it was expected that it 
would prostrate me entirely ; but in this we were agreeably disap- 
pointed, fori never felt so well as for about six months after- 
wards. One abscess (orifice) closed entirely, and the other 
almost ceased to discharge. 

At the end of March I began to experience a return of the old 
pains in the left side, which were attributed to my having walked 
too far in making an excursion down town. I had chills and 
fever, and the doctor feared that another abscess would form. 
Three weeks later an abscess pointed just beneath the scar formed 
by the first one. It was lanced, and discharged, but less freely 
than before. In all other respects, excepting this local trouble, I 
am well. 

In addition to the symptoms which this patient has detailed so 
intelligently, others were elicited on physical examination. While 
this last abscess was forming, the "touch" 
revealed a swelling of about the size of a 
pullet's egg in the left vaginal cul-de-sac. This tumor was 
somewhat soft and. very sensitive, so that when I pressed upon 
it my patient felt inclined to faint. The left border of the uterus 
and of the cervix were tumefied and puffy, or oedematous. The 



PELVIC CELLULITIS. 409 

Douglas' cul-de-sac felt thickened, indurated, and less supple 
than natural, giving the impression that (probably at the time 
she experienced the severe tenesmus of the bowel) there had 
been a retro-uterine tumor also. The vagina was hot and dry. 
Conjoined manipulation, with pressure in the left iliac fossa, 
could not be borne. The peri-rectal tissue was also indurated. 
The bladder and urethra appeared to have escaped implication. 
Abdominal palpation was not painful. The uterus was forced to 
the opposite, or right side of the pelvis (right latero-version), 
a displacement which might explain the prolonged and severe 
attack of neuralgia from which she had suffered more than a year 
before. 

I must not omit a reference to the fact that in this case the two 
first abscesses discharged above, and the last one below Poupart's 
ligament. She is taking calcarea carbonica 3 , morning, noon and 
night. 

Treatment. — -It has been said that practically it is not a very 

serious matter to be able to form a correct diagnosis between 

pelvic cellulitis and the diseases which so 

inferences based on cor- c i ose iy resemble it. But, gentlemen, I am of 

rect diagnosis. J 7 o 

a very different opinion. For, suppose a physi- 
cian should tell you that it was of very little consequence to him 
whether his patient had the pleurisy or the erysipelas, and that 
the treatment was substantially the same, no matter what the 
name of the disease, what would you say of him, and what would 
be the measure of your trust in him as a skillful and successful 
practitioner? And if we expect him to discriminate between 
pleurisy and erysipelas, why should he not also, when it is pos- 
sible, separate peritonitis from erysipelas ? In other words, if 
there is a difference in the morbid anatomy of inflammation 
which varies with its seat in particular tissues, and if these dif- 
ferences are always characteristic of the disease in question, why 
should they not modify the treatment accordingly ? Since the 
symptoms, course, and mode of termination of the diseases are 
really so unlike, is there any good reason why an inflammation 
of a serous membrane should be treated as if it were identical 
with an inflammation of the cellular tissue ? I think not. 

I know that it is possible, and that there is a strong temptation 
so to refine and to rarify the symptoms by which diseases are 



410 THE DISEASES OF WOMEN. 

differentiated as to leave no particular meaning in them, and to 
exclude a more practical idea of disease and its 

Pathological deductions. . 

treatment. But this is the other extreme. We 
must, and will always have, a theory of the disease which we 
undertake to cure. And, good or bad, true or false, that theory 
stands in our minds as a chart of its special pathology. Other 
things equal, the clearer and more correct our views on the sub- 
ject, the fuller will be the measure of our success and usefulness; 
for the physician who knows as definitely and accurately as possi- 
ble what it is that he wishes to cure, will usually exercise the 
greatest care in the choice of the means which he employs to 
that end. 

Now our clinical knowledge of the nature, peculiarities, com- 
plications, and tendencies of cellulitis enables us, not only to treat 
the symptoms that are present in the earlier stages of the disease, 
but to forecast and avert such as might and would otherwise fol- 
low. When we are called to a patient like either of those of 
whom I have spoken, and whose case is the groundwork of these 
remarks, we must cast about to see if we can not terminate the 
inflammation, or at least avoid some of its more serious con- 
sequences. 

And what are the consequences that we wish, if possible, to 

turn aside ? They are (1) to prevent the exudation of the liquor 

sanguinis, or serum, into the meshes of the 

General indications. . . n «, xr , . p . . - 

mtra-pelvic areolar tissue ; (z) it it has been 
already poured out, to promote its absorption and removal, and 
(3) to prevent suppuration, or abscess. These general indica- 
tions, therefore, correspond with, and concern the three last stages 
of pelvic cellulitis, viz. : effusion, resolution and suppuration. 

If we consider these enquiries in the order named, you will per- 
haps be able to obtain the best idea of the special therapeutics of 

pelvic cellulitis. It is as reasonable to suppose 

To prevent effusion. ... i • i i i _c 

that we nave remedies which are capable ot 
acting in such a manner upon the congested cellular tissue as to 
prevent effusion therein, as that we have those which are known 
to produce a similar effect in the first stage of serous inflamma- 
tions. There is no reason why, if we begin in season, many cases 
of threatened cellulitis should not be prevented from progressing 
beyond the stage of congestion. We ought to be able to cut short 



PELVIC CELLULITIS. 411 

this disease as we sometimes do pleurisy, peritonitis, synovitis, 
and pneumonia. 

Of course, if the patient is peculiarly susceptible, and the 
interna* conditions, as well as the external circumstances, con- 
spire to produce it ; and more than all, if we are not called in 
the incipient stage, or what is equivalent, do not know what dis- 
ease we are prescribing for, the chances are that effusion will not, 
or can not be prevented. But our duty is plain. If there are 
remedies that are capable of removing and relieving the accumu- 
lation and stagnation of red and white corpuscles in the vessels 
of this same connective tissue, and of thus averting the conse- 
quences that might follow, we should be prepared to prescribe 
them intelligently. 

The well-known effects of aconite in allaying the fever, in 
equalizing the circulation, in promoting a critical perspiration, or 
diuresis, and putting an end to threatened local 
inflammation, renders it very useful in this stage 
of the disease. The disease being consecutive to parturition, and 
allied as it is in most cases to surgical fever, the earlier this remedy 
is used the better. My own preference is to give it in the second or 
third decimal attenuation, and, under these particular circumstan- 
ces, to repeat the dose as often as every fifteen or twenty to thirty 
minutes. 

If the patient suffered extremely during labor, if labor was 

very prolonged, or if it was completed by instrumental aid, 

arnica may be used both topically and inter- 

Arnica. . ,.-.,.. 

nally. Ihere is no valid objection against alter- 
nating aconite and arnica for the relief of these symptoms. The 
arnica should, however, be given at longer intervals than the 
aconite, and, if you prefer it, in a higher potency. 

Belladonna has a specific relation to cellulitis, especially if it 
is of an erysipelatous type or character. In the outset of 

the attack it may even be preferable to 

Belladonna. . . . . 

aconite, providing there is not a very high 
degree of fever, and the nervous symptoms predominate. Given 
early and rapidly, it may suffice to avert the inflammation, par- 
ticularly in the case of nervous and delicate women, with arrest 
of the lochia, meteorism of the abdomen, throbbing headache, 
delirium and photophobia. Many experienced and reliable prac- 



412 THE DISEASES OF WOMEN. 

titioners prescribe aconite and belladonna in alternation for the 
relief of these symptoms, and are of opinion that, thus given, they 
do most excellent service. Whether or not the same prompt and 
desirable results could, in this instance, be obtained by the reme- 
dies given singly, my experience will not enable me to decide. 
Nor will the experience of any single practitioner settle this ques- 
tion for you. 

There is another remedy which I believe to be of incalculable 
service in the incipient stage of puerperal cellulitis, as indeed it is 
in puerperal peritonitis also. That remedy is 
the veratrum viride. Those of you who were 
present at the meeting of the Chicago Academy of Medicine, held 
last month (February, 1872), will remember the excellent report 
of Dr. W. H. Burt, of this city, on the physiological and toxical 
effects of this poison.* Its wonderful power to control and regu- 
late the vascular movements, to equalize the circulation, and, as 
it were, to stamp out a local congestion that would almost inevit- 
ably result in inflammation, is being recognized by physicians of 
all schools. 

My experience, as stated before the Academy during the dis- 
cussion on Dr. Burt's paper, has satisfied me that this remedy 
holds some specific relation to the female generative system. 
Precisely what that relation is, I can not say. But it appears to 
be especially adapted to the relief and removal of puerperal 
inflammation. For many years I have been in the habit of pre- 
scribing it whenever, in a lying-in woman, the first symptoms of 
pelvic, or peritoneal congestion show themselves ; and, when my 
directions have been faithfully followed, the result has been 
most happy. It restores the milk and lochia, when these have 
been suddenly suppressed, quiets the nervous perturbation, 
relieves the tympanites and the tenesmus, whether vesical or 
rectal, and frequently cuts short the attack. When called in 
season, I have seldom failed to set aside a threatened cellulitis 
by the same means. My custom is to give it in the second or 
third decimal dilution. In an urgent case, the dose should be 
repeated every twenty minutes or half hour, for four or five times 
successively, and afterwards less frequently. 

You will find the particulars of some very interesting cases of 

* See the U. S. Med. and Surgical Journal, Vol. VII, page 268. 



PELVIC CELLULITIS. 413 

erysipelas cured by the local and general use of the veratrum 
viride in Prof. Hale's work on Materia Medica.* 

In addition to the faithful employment of one or more of these 
internal remedies, it may serve a good purpose, and can do no 
possible harm, to resort to the local use of dry 
heat by means of hot flannels, or of a dinner 
plate that has been immersed in hot water, wrapped in flannel 
and then placed directly over the seat of the pain. Sometimes 
great good can be effected by applications of towels or cloths 
wrung out of hot water, and frequently repeated. But best of 
all is the simple, old-fashioned bran poultice that I have so fre- 
quently recommended you not to forget in cases of threatened 
puerperal inflammation of whatever variety. 

For the stage of effusion, which in many, and perhaps in a 
majority of cases (as you will be called to them in private prac- 
tice), can not be averted, a different class of 

For the stage of effusion. . . 

remedies are certain to be indicated. Promi- 
nent among them are apis mellifica, arsenicum alb., bryonia, rhus 
toxicodendron, digitalis, cantharis, mercurius sol., stibium, helle- 
borus niger, colchicum and sulphur, which may be given accord- 
ing to the particular symptoms, or group of symptoms that are 
present. 

Concerning the use of the apis mel., which is an invaluable 
remedy at this stage of the complaint, I am of the opinion that 

man}^ physicians have failed with it because 

Apis mel. . 

the preparation which they have given has not 
been trustworthy. In 1868, my friend, Dr. J. D. Craig, of Xiles, 
Mich., sent me a trituration of the remedy which he had prepared 
and prescribed with excellent effect. His method was to extract 
the sting of the honey-bee, and its poison-bag also, with a pair 
of forceps, and then to triturate these with the saccharum lactis 
in the proportion of two grains of the sugar to one sting. This 
he called the first trituration, from which others could be made 
in the usual manner. I have prescribed this preparation in the 
second stage of cellulitis, and in dropsical disease, with good 
effect, and can therefore recommend it to you. 

But, if you desire to facilitate resolution, and to counteract the 

* The Horn. Mat. Medica of the New Remedies, by E. M. Hale, M.D., etc., second 
edition, 1S67, page 1053. 



414 THE DISEASES OF WOMEN. 

tendency to suppuration (which indications are identical), it is 
indispensable for you to put your patient upon a 
good diet. If the digestion is impaired, and food 
can not be taken, or tolerated, that disorder should be corrected 
as speedily as possible. And, when it is remedied, you must see 
to it that your patient is not starved into the very condition that 
you wish to avoid. For in most cases of this kind, the quantity 
of serum effused, the size of the tumor, and the risk of abscess 
bear a proper relation to the impaired quality of the blood, and 
to the too rapid destruction of tissue that is going on in the sys- 
tem. And, unless the patient's strength is fortified against it, 
you will learn when it is too late, that either a passive, but very 
extensive, infiltration of serum has taken place, or that pus has 
already been formed and is seeking an outlet. 

Under these circumstances, therefore, do not permit the febrile 

condition to mislead you. If such a result were desirable, a rigid 

diet would be the very best means of inducing 

Caution. . . 

a hectic lever and its attendant symptoms. Jb or 
the weaker your patient, the greater the liability to fever and to 
the non-removal of the tumor, excepting through the process of 
suppuration. In puerperal women, especially, whose strength 
has been taxed during gestation, and who have survived the mar- 
tyrdom of labor, there is a strong predisposition to the diathese 
de suppuration of Trousseau. If you persist in keeping them 
upon an insufficient aliment, the best chosen remedies will not 
help you out of the difficulty. Indeed this is one of those condi- 
tions in which good food may be worth more than medicine. 
I firmly believe that the patient who was before you at my last 
lecture, would have died during her first week in the hospital if 
she had not been properly nourished. 

Nor do I know of anything that is more beneficial in some of 

these cases than certain preparations of alcohol. There is no 

danger of exciting inflammation or fever by 

Stimulants. . 

the proper use of the best brandy, or whiskey. 
Stimulation will be well borne, and may bridge over the chasm. 
The alcohol acts most beneficially if mixed with some nutrient, as 
for example, with milk, the whites of eggs, or beef tea. Two or 
three table-spoonfuls of milk punch may be given every one to 
four hours, according to circumstances, and continued until the 



PELVIC CELLULITIS. 415 

crisis has passed. Wine will not suffice. The malt liquors will 
.answer a better purpose farther on. 

Certain external means may conduce to the same end. I have 
great confidence in the bran poultice already recommended. It 
may be applied day and night for an indefinite 
period. Where the induration, or rather, the 
tumor is above the brim of the pelvis, an excellent expedient, 
designed to facilitate its resolution, is the local application of the 
camphorated oil, which consists, as you know, of gum camphor 
dissolved in olive oil. The inflamed region should be thoroughly 
anointed with it, and then covered with a thick layer of cotton 
batting. If the pain is very acute, and more especially if it is 
ovarian, one part of the tincture of hamamelis may be added to 
four parts of hot water, and applied topically by means of a com- 
press. If the cellulitis is of traumatic origin, arnica may be used 
in the same way. A blister would de-vitalize the tissues and do 
positive harm, and so also would the tincture of iodine. Abso- 
lute rest is indispensable to the cure. 

The best general rule for the treatment of the suppurative stage 

is to avert it if you can, but to promote the discharge of pus if 

you must. If you find that an abscess really is 

To promote suppuration. 

forming, no matter where the fluctuation may 
first be observed, give the patient hepar sulphuris, calcarea carb., 
mercurius sol., sulphur, or such other remedies as the symptoms 
may require. Or, if the discharge has already been too copious 
and long continued, silicea may be prescribed with a view to its 
arrest. 

Emollients of linseed meal, slippery elm, or bread and milk, 
hot fomentations and the hip-bath will sometimes afford relief to 
the pain and hasten the formation and discharge of pus. Or you 
may apply warm water per vaginam by means of a syphon, so as 
to facilitate the same process internally. 

If the abscess points externally (and it is most desirable that it 

should do so), it may and should be lanced so soon as it is ready 

to discharge. Wait until the integument cov- 

How to open the abscess. . 

ermg the tumor has softened and become thin ; 
and be careful to make the puncture as low down as possible in 
order not to open the cavity of the peritoneum. It is safest to cut 
close to Poupart's ligament, more especially from the middle por- 



416 



THE DISEASES OF WOMEN. 




tion of the ligament outwards, in order to shun the sheath of the? 

the femoral vessels. Some authorities recommend to make a val- 
vular incision in opening" 
these abscesses, in order 
to avoid the possible in- 
troduction of the air into 
the abdominal cavity. 

Unless there is a very 
decided fluctuation of the 
tumor along some por- 
ion of the vaginal wall 
or roof, or you are posi- 
tive concerning the pres- 
ence of pus therein — from 
having brought it away 
fig. 36. The vaginal douche, with the exploring needle 

— you will not be warranted in opening it per vaginam. For there is 

danger in such a case of wounding some of the pelvic viscera. But 

when there is a point of fluctuation, 

you may puncture very carefully and 

evacuate it as you would if it were^ ( 

a more accessible hematoma. It is 

safer, as in hematocele, to lance such 

an abscess through the vaginal sep- 
tum, than from the rectal side of the 

tumor, because of the greater number 

of small vessels that are supplied to 

the latter. Whenever it is possible 

the sac should be entirely emptied, else 

a fistula may form and remain. 

Fig. 37. A vaginal syphon. 

In suitable cases the abdomen may be opened, the abcess 
emptied, its margins stitched into the incision, 

Laparotomy and drain- j xi ji j j j • j mi_ ■ ' • 

age in. and the wound closed and drained. This is a 

severe and hazardous remedy, and should not be 
resorted to without all the precautions and skill that are necessary 
in the worst cases of abdominal surgery. The contra-indications 
for the employment of this measure, preceded as it should be by 
a careful exploratory incision, will be considered farther on. 




LECTURE XXVI, 



TEL VIC HEMATOCELE. 



Pelvic fcasmatocele, clinical history; etiology. Case.— symptoms; diagnosis. Case.— prog- 
nosis. Case.— treatment, palliative, (Case,) medical and surgical. Cases. 

Definition and clinical history. — An hematocele is a tumor 

composed of blood that has been effused, and which has become 

more or less solid. A pelvic hematocele is a 

Definition and vane- bl d tumor that has been formed within the 

ties of. 

pelvis, and which, both from its origin and loca- 
tion is connected with the internal generative organs. Various 
qualifying terms have been applied to these tumors, as for example, 
they are called peri-uterine, because they are outside of the wonib, 
but in its immediate vicinity; retro-uterine when they are in the 
Douglas' space; vesico-uterine when they are located anteriorly, 
between the uterus and the bladder; intra-peritoneal when the 
blood of which they are composed has been poured into the peri- 
toneal sac ; and extra-peritoneal when it has been emptied into 
the cellular tissue. 

The intra-peritoneal variety has also been styled the true and the 
encysted hematocele, in distinction from the false, the pseudo, 
the non-encysted and extra-peritoneal hematocele. Some writers 
call the latter a thrombus. By drawing a parallel between the 
recto-vaginal fold of the peritoneum, in women, and the tunica 
vaginalis testis in men, Bernutz concludes and insists that true 
hematocele can only take place within the peritoneum. 

But these qualifying terms only serve to indicate the accidental 
location and anatomical relations of the tumor. Xeither of them is 
sufficiently comprehensive to include the whole subject, nor do they 
represent so many varieties of the same affection. For this reason 
we prefer the general term pelvic hematocele. 

Let me observe in the outset, that a hematocele is not a disease 
per se, but a contingent of certain intra-pelvic disorders, as for 
example, of amenorrhcea from cervical occlusion, menorrhagia and 

417 



i 



418 THE DISEASES OF WOMEN. 

metrorrhagia, abortion, extra uterine pregnancy, and pachy-peri- 
Not a disease per M toi ^is. It is always either a secondary, or an 
accidental affection, but it is none the less im- 
portant on that account. Indeed, it is a very serious condition, 
and therefore I am anxious that you should have a clear and prac- 
tical idea of its pathology and treatment. 

The clinical history of pelvic-hematocele is consequently varied. 

Its advent, its course, its complications and its final result wiL 1 

depend upon the nature and severity of the 

Its clinical history is v ilu • ' • i • 1 «.l • n 

not constant. disease or the injury upon which it is secondary. 

It Avill also be modified, in a manner at least, by 
the general constitution of the patient, by the hemorrhagic 
diathesis, and by the slowness or the rapidity with which the effu- 
sion and the extravasation of the blood has taken place. 

Etiology, — The causes of pelvic hematocele are predisposing and 

exciting. In many cases a plethoric condition of the system, with 

a tendency to a profuse and prolonged menstrua- 
Predisposing- causes. . „ 

tion precedes the attack. A copious now of the 

menses predisposes to hematocele when that flow is intermittent 

and very irregular. Sometimes those women who tor some cause 

are anaemic, or in a state of chloro-anemia, are 

Catamenial disorders. ,.,,..,«, A . r , 

liable to the formation of these peri-uterme 
tumors. This is especially true in case the condition of the blood 
has induced an attack of amenorrhcea. Briefly, whatever consti- 
tutional or local causes is capable ot arresting or deranging the 
catamenial function may incline the patient to this affection. 

Marriage seems to have no influence in the production of this 
disease, at least in so far as the proper marital relation is con- 
cerned. Hematocele may and does arise, however, 
from sexual excess, and also from abortion, from 
extra-uterine gestation, and even from labor at term, but this can- 
not be properly charged to the marriage relation as a predisponant 
of hematocele. 

Ao;e has its influence, for we find that attacks of this disease are 

comparatively more frequent among those whose sexual vigor is 

most pronounced, and at a period of life when it 

Age and sexual vigor. . 

is most active. Inis period extends from 
twenty to thirty-five years of age. 

Women of an hemorrhagic diathesis are more prone than others 



PELVIC HEMATOCELE. 419 

to this accident; for this state includes a weak and varicose con- 
dition of the veins, not only in the lower ex- 
The hemorrhagic tr emities and in the external parts, but also of 

diathesis. A 

the internal organs and surlaces. Clinically 
there is very little difference between a varicose condition of the 
hemorrhoidal veins and that of the utero-ovarian vessels. And, 
when either of them is ruptured there will be an escape of blood 
from the anus, or an extravasation of it within the pelvis, accord- 
ing to the location of the lesion. 

The blood itself may become so depraved in quality as a result 
of the zymotic diseases, like scarlatina, v r ariola, diphtheria, malig- 
nant jaundice, or purpura, as to incur the risk 
of its effusion or transudation from the free sur- 
face of the inflamed peritoneum. For in this class of cases we 
may have a hemorrhagic peritonitis as well as a hemorrhagic 
pleurisy. 

Pelvic peritonitis may predispose to pelvic hematocele by reason 

of the adhesions and false membranes which have been formed 

during its course. These sequele are not directly, 

Pachy-peritonitis. ., n . , _ 

or necessarily, of a serious character: but, as 
Virchow and Bernutz have shown, there is a possibility that the 
delicate vessels which ramify upon these neo-membranes may be 
ruptured, and a haemorrhage result. This is what is understood 
by pachy-pelvi-peritonitis as a preclisponant of hematocele. 
Those of you who are interested in the study of this peculiar sub- 
ject will find the remarkable monograph by Bernutz in the Ar- 
chives de locologie, des Maladies des Femmes, etc., for March, 
April and May, 1880. 

The exciting causes include various traumatic injuries, as for 
example, blows upon the abdomen, falls upon the buttocks, the 

effects of jumping and of beino; thrown from a 

The excitin" causes. *"" 

carriage, and rough riding on horseback, especi-* 
ally when these are applied during the menstrual epoch. Voisin 
reports several cases that were due to the indulgence of coitus 
during menstruation, and other writers have attributed it to a 
violent shock or fright during sexual intercourse. It may some- 
times be caused by lifting, by straining at stool, by over fatigue, 
intense mental emotions, or by too early exercise after an abortion. 
Nonas reports two cases in which it was caused by the use of cold 



420 THE DISEASES OF WOMEN. 

injections during menstruation ; and others have known it to arise 
from the application of cold sponges and compresses to the vulva 
during* the monthly flow. 

Whatever is capable of arresting this periodical discharge very 
abruptly may precipitate this form of internal haemorrhage. The 
resort to vaginal and intra-uterine injections for the relief of men- 
orrhagia, or to stop the flow after an abortion, may have the effect 
to turn the tide the other way, and to cause an accumulation of 
blood within the peritoneal or the cellular tissue of the pelvis. 
The same is true of the use of the sponge tent for plugging the 
cervix uteri, and of the tampon, when the uterus may fill with 
blood and force an outlet through the Fallopian tubes into the 
peritoneal cavity. 

It has been suggested that the menstrual blood, after having- 
been retained in utero for a greater or less length of time, might- 
be very poisonous when brought into contact with the peritoneum. 
Pure, healthy blood, it is said would not induce peritonitis ; but, 
if the blood was depraved, either in the general circulation, or 
when it came into the peritoneal cavity from some special source, 
it would be very likely to cause septic infection, as well as a serious 
inflammation. 

There are exceptional cases in which hsematocele evidently 
results from a partial or complete stenosis of 

sJno^s? erVlCal the cervix uteri * We have hacl one of these 

under our observation for three.years past. The 

facts were as follows : 

Case. — Mrs. , aged twenty-eight, a slender, delicate woman 

who had been married for six years, but without offspring, and 
with no history of an abortion, consulted us for the relief of a very 
severe headache to which she had been subject much of the time 
since her first menstruation at the fifteenth year. Of late, the 
headache had become decidedly menstrual, anticipating the flow r 
some twelve or twenty-four hours, and being always somewdiat 
relieved by it. But the monthly discharge was so scanty and 
escaped with such a stillicidium, that she felt satisfied that the 
retention must have something to do with her suffering. She had 
long been subject to haemorrhoids. 

I gave her remedies for some time, but without effect, and finally 
obtained permission to make a careful internal examination of the 
uterine cervix. She would not consent to this until she had satis- 
fied herself that quite recently, indeed at her last period, she had 



PELVIC HEMATOCELE. 421 

felt something quite wrong and unusual within the pelvis. I felt the 
conical cervix crowded forward towards the symphysis pubis by a 
retro-uterine tumor, that was of irregular form and doughy to the 
touch. Around its outline the tissues were very tender. Unfor- 
tunately, I could not know how long this state of things had 
•existed. 

The tumor was bi-lobular, with a kind of sulcus between the 
lobes that could easily be felt by the rectal touch. This sulcus, 
indeed, corresponded in shape, size and direction with the rectum 
itself. She had had a great deal of sacral pain, and of dragging 
in the hips and the loins, but the bowels were regular. The 
sacral distress was usually very severe at the month. 

There was an almost complete stenosis of the uterine cervix, and 
only the smallest sound could be passed through the internal os uteri. 
With the absence of the signs of pelvic cellulitis, and of an uterine 
fibroid, the case was diagnosticated as one of menstrual hematocele, 
due to a reflux of blood from the uterine cavity. 

A careful dilatation of the uterine canal was begun and continued 
throughout the inter-menstrual period. "When the month came 
around, the flow was much more free, and she had very little head- 
ache. The strictest quarantine and rest were enjoined for a week 
during the period, and then the careful dilatation of the cervix 
was resumed. In three months the menstrual trouble and the 
headache had vanished, and, by a free coffee-ground discharge from 
the rectum, the tumor had almost entirely passed away also. For 
the last two years she has been quite well. 

The intra-peritoneal haemorrhage in hematocele has been attrib- 
uted to various sources. Thus, Bernutz ascribes it to menorrhagia 
with a regurgitant flow of the menses through the 
rh S a g u J ceot ' thehfemor - oviduct:^ Xelaton, to the rupture of a Graafian 
follicle, and the gravitation of blood into the 
retro-uterine pouch : Virchow, to the rupture of the newly-formed 
vessels in the false membranes that have resulted from a local 
peritonitis: Peuch, Bichat and Devalz, to a rupture of the utero- 
■ovarian vascular plexus; Tilt and G-enouville insist that it comes 
from the ovary; Trousseau and Tardieu, to a sanguineous exhal- 
ation from the peritoneum; Tyler Smith, to an ovarian or Fallo- 
pian menstruation, which is vicarious in character; and Gallard to 
the escape or dropping of the ovum into the peritoneal cavity, or 
in other words, to the detachment of the ovum in extra-uterine 
gestation. 

Other causes that have been noted are a rupture of the Fallopian 
tube and of the ovary, the detachment of the fecundated ovum in 



422 



THE DISEASES OF WOMEN. 



tubal pregnancy, and the sudden arrest of the lochia after confine- 
ment. 



Symptoms. — As a rule, the more sudden the attack and the 
greater the loss of blood, the more likely is the tumor to be of the 
non-encysted variety. For a slower and more scanty extravasa- 
tion within the peritoneum is almost certain to excite an adhesive 
peritonitis, in consequence of which, the walls of the haematic cyst 
are formed. So that, while the immediate danger corresponds 
with the suddenness of the attack and the profuse escape of blood, 
in the former case, in the latter, the pain and local suffering are 
the most pronounced. 

The symptoms are local and general. The pathognomonic sign 
is found in the presence of a tumor which is located at some por- 
tion of the roof of the vagina. The physical 
characters of this tumor, when it is large enough 
to extend above the pubis, or into the iliac region, are dullness on 
percussion, irregularity of outline, tenderness on pressure, partial 



Local gymptoms. 




Fig. 38. Clover-leaf form of hematocele,, 

or complete fixity, and elasticity with a sense of fluctuation which 
soon gives place to an unequal density, (like the tumor of pelvic 
cellulitis.) When this tumor rises above the superior strait, it 
may take the clover-leaf form, as seen in this drawing. 

The signs per vaginam are the recognition of 

the base and inferior outline of the tumor; 

the dislocation of the cervix, forwards, back wads, or laterally, 



PELVIC HEMATOCELE. 423 

by the pressure of this foreign body; great tenderness on pres- 
sure in one or all of the culs-de-sac; and immobility ol the tumor 
and of the uterus. 

The largest tumors are almost always intra-peritoneal, and are 
naturally retro-uterine. The smallest are at the anterior cul-de- 
sac, because the vesico-uterine pouch, except in advanced preg- 
nancy, is too shallow to contain a large quantity of blood. The 
more prolonged the stage of fluctuation in the tumor, the greater 

the certainty that its outline is not limited by 
tumo 1 ?^ SiZG ° f thG a cyst-wall, and the greater the probability that 

the effused blood is impoverished and lacking in 
fibrine. The conjoined manipulation and the rectal touch are very 
useful in detecting these haematomata. 

Voisin's* description of the mode of formation of these tumors 
is very graphic : 

" When blood escapes ^rom the ovaries, the tubes, or the uterus, 
it tails naturally behind the broad ligaments 
ihe?um°o f r. f0rmati0n0f illto the retro-uterine peritoneal space, limited 
before by the broad ligaments and uterus, behind 
by the rectum and lateral folds of the peritoneum, — on all sides 
by serous membrane. Above, the cul-de-sac is open, and commu- 
nicates largely with the rest ol the abdominal cavity. In some 
rare cases the blood is carried in part into the vesico-uterine space, 
but in a very small proportion compared with the mass extrava- 
sated behind the uterus. Hardly have some drops of blood pene- 
trated into the serous cavity than it inflames. This inflammation 
results in speedily establishing adhesions between all the pelvic 
organs, or rather between their peritoneal covering's. The coils 
of intestine are pushed upwards by the extravasated fluid, or rise 
upward by their own lightness. The collection of blood encysts 
rapidly, thanks to the energy of the inflammation of the serous 
membranes and the formation of cellular adhesions. The sides of 
the tumor are then limited, before by the broad ligaments, behind 
by the rectum and peritoneum, below by the recto-uterine cul-de 
sac, above, by the coils of intestines which, by their adhesions to 
the fundus uteri, the broad ligaments, the ovaries, the tubes, the 
round ligaments, and the peritoneum which covers the lateral 
parts of the pelvis, forms for the cyst a sort of resisting roof." 

The uterus may or may not be moved independently of the 
tumor. Not unfrequently it is in a state ol subinvolution. If the 
retro-uterine tumor is large and dense, the cervix may be pushed 

*Del' Hematocele Retro-Uterine, Paris, 1860. 



424 



THE DISEASES OF WOMEN. 



Fixation of the 
uterus. 



behind or above the pubis, and the rectum obliterated. If the 
ante-uterine tumor is large enough, the fundus and body of the 
womb may be retrovertecl. If the effusion has 
taken place on all sides oithe uterus, that organ 
may be fixed as in a mould or cast when the 
tumor begins to harden. Ketro-uterine haematomata may distend 
the Douglas cul-de-sac until it reaches the floor of the pelvis, or by 
pressure may induce an infiltration of the recto-vaginal septum. 
It is very rare to have more than one of these haematic tumors in 
the same patient. (See Figs. 39 and 40.) 

In some cases these tumors diminish in size from time to time. 
If we can prevent a repetition of the flow, especially in menor- 
rhagia, they will shrink as they become more 
solid, until finally they are removed by absorp- 
tion, cr by their suppuration and discharge through one of 
the pelvic outlets. This fact may be confirmed by means of a care- 
ful bi-manual examination repeated now and then. 



Changes in the tumor. 




Fig. 39. Intra and extra-peritoneal hsematocele. 

If the haemorrhage happens to occur when the rectum is loaded 
with faeces, the tumor may be moulded into such a form as after- 



PELVIC HEMATOCELE. 



425 



Form of the tumor 
exceptionally. 



wards to exempt the patient from rectal tenesmus, which usually 
is one of the most distressing symptoms in retro- 
uterine hematocele. And strangury may also 
be lacking as a symptom if, during the solidifi- 
cation and encystment of the tumor, the patient has invariably 
Jain upon her back. 

Pelvic hematocele is so often related to menstrual disorders 

lhat the first symptoms are generally connected with amenorrhoea, 

menorrhao-ia or dvsmenoiThcea. If a copious 

General symptoms. ° " 

menstral now is suddenly arrested, and a hema- 
tocele results, its onset will be very abrupt; but if the menstrual 
flow escapes very sloAvly, drop by drop, the tumor may develop 
gradually, and the general symptoms will come on imperceptibly. 
In the former case the sudden shock as well as the loss of blood, 
may induce fainting and prostration. In both conditions, when 
the hematic tumor is formed, the external flow ceases. 




Fig. 40. Intra-peiitoneal haeimito; e'.e. 

The larger the' size of the tumor, the greater the amount of 
blood eftused, and the more sudden the attack, unless in very 

exceptional cases, the less marked are the sio-ns 
to ^ s coincidentperi - of a coincident peritonitis. And hence, at the 

very beginning, the pain is not always a criterion 
of the gravity of the case. If the attack has come on slowly, or 



426 THE DISEASES OF WOMEN. 

the extravasated blood has been poured into the connective tissue, 

or into the peritoneal sac, when those parts are 

already inflamed, the suffering w 7 ill be very 

severe. Large accumulations give rise to great suffering, how- 

ever, when they have existed for a little time. 

The pain, which is perhaps more agonizing than even a woman 
is called upon to endure, under other circumstances, is located 
about and within the pelvis and the lower abdomen. Sometimes 
it is paroxysmal, and partakes of the character of labor pains ; 
again it is confined to the sacral region, and is referred to the 
rectum, where it causes an insufferable tenesmus. In some cases 
there is a distressing strangury, and in others an absolute inability 
to stand. But this pain, wherever located is excrutiating in char- 
acter, lancinating, expulsive, or neuralgic, with a feeling as if the 
intra-pelvic tissues were being torn and lacerated. 

If the attack has been very abrupt and severe, there will be loss 

of blood and such a shock to the nervous system as to induce 

syncope and collapse, with coldness and pallor 

Other symptoms. _ . _ . . , , . . , . 

ol the surface, pinched features, hiccough and 
vomiting, and an almost imperceptible pulse. These symptoms 
bear a pretty constant relation to the amount of^ blood that is 
effused, and may be so overwhelming as not to be followed by reac- 
tion. Their suddenness and gravity are like those which are due 
to perforation of the bowel in typhoid fever. A very remarkable 
case of this kind was reported to the Clinical Society of our Hospi- 
tal last year by Dr. E. F. Baker, of Davenport. 

In milder cases the suffering is mitigated after a few hours y 
but, in consequence of increased effusion or of an extension of the 
peritoneal inflammation, it is likely to return. 
^ mid and relapsing Exceptionally there is a relapse at each return- 
ing menstrual period. When the effusion is 
gradual and is limited to the pelvic cellular tissue, the suffering 
may be comparatively slight; indeed, there is reason to believe 
that, through the good results of menstrual quarantine, many of 
these cases pass without recognition. 

The remaining general symptoms are those of pelvi-peritonitis ; 
and they are modified as the case passes through the different 
stages of resolution, suppuration, and discharge. The digestive 
disorders, more especially the bilious vomiting and loss of appe- 



PELVIC HEMATOCELE. 427 

tite, are limited to the first stage of the affection, but, for mechan- 
ical reasons, dysentery, or a dysenteric diarrhoea, 
symptoms in the . ]ikel t b ; developed. The fever varies ac- 

later stages. _ J l 

cording to circumstances. If the pain and the 
peritonitis are marked, the temperature and the pulse will be 
increased; but, if the haemorrhage has been great and sudden, the 
temperature will be low and the pulse feeble. 

When the duration of the disease is prolonged, a marked and 
persistent anaemia is developed. The color of the skin resembles 

that of chlorosis, and because of occasional or 

periodical relapses of the disease, it may become 
permanent. The coincident peritonitis may increase or continue 
until it becomes suppurative, and an abscess may form about the 
haematic cyst. The accompanying symptoms will include the signs 
of the suppurative form in addition to those of haematocele. 

Diagnosis. — In a differential way it is more difficult to distin- 
guish between a pelvic abscess, or pelvic cellulitis and pelvic 

haematocele, than between haematomata and any 

iius r .° m PGlViC CeUU " other class of P elvic tumors. ll1 m y lectures on 
pelvic cellulitis, I have already given you the signs 
by which we separate these two diseases. This is a very import- 
ant subject and one that merits your careful attention. The great 
Nelaton, mistaking a pelvic abscess for a pelvic haematocele, punc- 
tured the tumor through the posterior wall of the vagina, and 
discharged an immense quantity of pus instead of blood. 

Nor is it always easy to avoid confounding this disease with 
uterine fibroids. The chief points to remember are that in haema- 
tocele the tumor forms and orows rapidly ; that 

From uterine fibroids. ' . t i 

its formation is accompanied by grave constitu- 
tional symptoms; that the tumor is regular in its outline, and 
soft to the touch, growing more dense as time goes on ; that its 
presence causes the most intense suffering which may continue, or 
repeat itself; and that, if it is retro-uterine, it displaces the 
uterus upwards and forwards as no other pelvic tumor is likely to 
do. The very opposite is true in the case of uterine fibroids, for they 
are of slow and gradual growth, without any special or dangerous 
constitutional symptoms; the tumor is more or less irregular in 
outline, and hard from the first; its presence is tolerated without 
severe pain, and it does not displace the womb in any particular 
direction. 



428 THE DISEASES OF WOMEN. 

Although these differential symptoms may appear very plain 
and quite sufficient, great care is requisite in deciding between 
these two affections. For the celebrated Malgaigne, of Paris, and 
the no less distinguished Stoltz, of Strasbourg, each mistook a 
pelvic hematocele for a uterine fibroid. The former did not dis- 
cover his error until (in 1850) he had made an incision into the 
os uteri with the intention of enucleating the tumor; and Stoltz, 
was so confident of his diagnosis, that he made his patients' case the 
subject of several lectures upon fibrous tumors of the uterus. 
In the latter case the existence ol the hematocele was not dis- 
covered until 1he autopsy was made. 

Bernutz and Goupil could not decide, in a case at the Hotel 

Dieu, whether it was an haematic tumor or a uterine fibroid; and 

several cases are on record in which a larg-e haematocele was 

mistaken for an ovarian cyst. Indeed, in one case, recorded in 

^ jjg Mr- aM _ M j ig^» the Transactions of 'the Lon- 

/^^ - ■ -£jp don Obstetrical /Society, the 

H % ~~"~jk /^^^l °P era ti° n tor ovariotomy 

^Ara: |lif Jjf was actually begun under 

«l ^ P ' r ^ ^ig^r a misapprehension of this 

If we except the very rare 
cases of ovarian tumor in 
which there is a haemorrhage within the cyst, there should be no 
danger ot mistaking a case of pelvic hematocele 

From ovarian dropsy. P ™ . . . . 

tor one ot ovarian dropsy. I lie history ot the 
case, including the mode of formation of the tumor, the incidental 
suffering, the constitutional symptoms, the menstrual or puer- 
peral complications, and finally, the tapping of the tumor will 
enable us to decide between them. 

Extra-uterine gestation is always accompanied by some of the signs 

of pregnancy ; the tumor is of slow growth,andis generally painless. 

If the vascular attachments of the ovum are not 

From extra-uterine brok th . RO raye constitutional Symp- 

pregnancy. ' o j l 

toms ; but if they are ruptured, we shall have 
symptoms of pelvic haematocele superadded to those of extra-uterine 
pregnancy. 

Case. — In a very remarkable case of this kind to which I was 
called in consultation in December 1879, by my friend Dr. Thomas 



Fig. 41, The aspirator. 



PELVIC HEMATOCELE. 



429 




Fig. 42. Drawing- of an hematic tumor resulting from a rupture of the sac containing 

TorWvZVeZlZrT 11 ^ T , MS tUm ° r W3S Sh ° Wn t0 ^CoUe^e and HospS TcZ 
Rnw«I t V S ltS removaL The f acts as illustrated were also confirmed by Drs 

ope"S n LUngren ' Parmellee ' and ° thers ' who were P-sent and who assSted ta the 



PELVIC HEMATOCELE. 431 

Bowsey, of Toledo, Ohio, the pregnancy was ovarian, and the sac 
and its attachments had been ruptured at the eighth week, with a 
resulting hematocele of the right broad ligament. Even at so 
early a period, Dr. Rowsey had very skilfully recognized the case 
as one of extra-uterine gestation, and when the rupture took place 
and his patient was in great peril, I was sent for to decide upon 
the exp3cliency of an operation for the removal of the tumor. We 
determined upon gastrotomy, and found the right broad ligament 
to be the seat of an haematic tumor larger than my fist, at the 
upper and inner angle of which the dark blood was oozing into 
the peritoneal cavity. The sac upon the right ovary had been 
ruptured and was filled with soft blood-clots, and the embryo 
with its rudimentary cord was immersed in fibrinous clots, and 
fluid blood. The whole mass ;was carefully removed by the ecra- 
seur, taking the broad ligament along with it. The patient re- 
acted well, but for some unknown reason, since a post-mortem was 
not held, she died on the third day. (See Fig. 42.) 

The diagnosis of retro-uterine hematocele from retroversion of 

the uterus is made out quite readily. The signs revealed by the 

conjoined manipulation ; the possibility of lift- 

From retro-version - tfa tmnor the ab sence of the agonizing 

of the uterus. fa ' . fa - fa 

peritoneal pain, and of the vomiting and the 
collapse of hematocele ; and the confirmation of the displacement 
by the passage ot the uterine sound or probe, enable us to detect 
the uterine deviation with a good degree of certa'nty. 

In doubtful cases, and as a last resort, the exploring needle or 
the aspirator may be called into requisition to settle the diagnosis. 

But these instruments should be used with the 
«3SS!!»*"««« ta8t care, and not indiscriminately. They 

are most decidedly contra-indicated if the tumor 
is very large, and if its contents do not solidify. If the tumor is 
very hard they reveal nothing ; and even when it is soft the fluid 
may be t^o thick to run through the canula of so small a trocar. 
If upon the withdrawal of the instrument a few drops of pus are 
brought away we shall know that the case is one of abscess with 
or without an hematocele. I have already shown you the aspirator. 
(See Fig. 41.) The needle, or the trocar, after being carbolized, 
should be passed on the vaginal side of the tumor. 

Prognosis. — If the effusion is slight and the tumor is circum- 
scribed ; if the accompanying peritonitis is local and adhesive ; 
if the general condition of the patient is good, and the attack does 



432 THE DISEASES OF WOMEN. 

not repeat itself too often, a gradual recovery is the rule. This 
result is likely to happen in the extra-peritoneal, or cellular 
variety, more especially if the collection of blood is not so large 
as to break through into the peritoneal cavity. The latter form 
of the haematic tumor is, however, very likely to terminate in 
abscess. 

But if the patient is of an hemorrhagic diathesis, and the loss 
of blood is sudden and large : if the shock and collapse at the 
onset of the attack were pronounced and the reaction intense; if 
the tumor continues soft and flabby, the pulse weak and feeble 
and the appetite poor; if the anaemia continues, and the chlorotic 
hue does not give place to the florid complexion; if the attack 
was menstrual, and there is a probability of a relapse at the next 
or subsequent periods; if the rupture was tubal, ovarian, uterine,, 
or the consequence of an extra-uterine pregnancy ; if the case is 
complicated with diffuse peritonitis, more especially if it is puer- 
peral ; or if there is a concurrent suppuration, or a consequent 
cachexia, the prognosis is generally unfavorable. Even in chronic 
cases where these haematomata empty their contents into the 
rectum there is danger that the haemorrhage may be renewed and 
become so excessive as to be beyond control. 

I ought, however, to say that of late, unless they are over-whelm- 
ingly fatal in the first stage, cases of pelvic haematocele are more 
readily controlled than in former times. This result depends upon 
our having a more correct idea of their special pathology than was 
possible twenty years ago. And, consequently, upon our know- 
ing enough to avoid the added dangers of a mischievous interfer- 
ence with what we do not understand. 

Treatment. — The treatment is palliative, medical and surgical. 
Absolute rest, to be enjoined, not only because it gives compara- 
tive exemption from pain, but also because it is 

Palliative treatment. . . n , 

the best means of preventing an increased enu- 
sion of blood, or a relapse. The patient will choose the position 
which is most easy, and she should be permitted to keep it. It 
may be necessary to insist that she shall remain in bed through 
two or more consecutive menstrual periods. And not only should 
she be kept quiet, but the bowels should be at rest, and not wor- 
ried by cathartics, or even by enemata. I have known a case in 
which a relapse of an haematocele was induced by strangury. For 



PELVIC H2EMATOUELE. 433 

a lono- time after an attack of this disease sexual intercourse should 
be strictly forbidden. 

In serious cases it becomes a question whether our dislike of 
opiates should notyield to our desire to relieve the terrible suffer- 
ing that is incident to the haematic tumor. If we had a remedy 
or remedies exactly suited to all the symptoms in the case, and 
if the ill effects of the narcotic were not more than counter- 
balanced by the rest that it brings, and the consequent exemption 
from an increased extravasation of blood, I would advise you never 
to resort to morphine in this class of cases. You may get along 
without it if you can, but, the tact is that in very bad cases you 
will be forced to give it, although under protest. 

Other means of assuaging the pain and of preventing an increased 
effusion ot blood are to resort to hot water injections per-rectum, 
or per-vaginam. You may add two tablespoonfuls of the mother 
tincture of hamamelis to a pint of very warm water, and throw it 
into the rectum or the vagina. Or compresses wet with the same 
solution may be applied over the pubis and the vulva with good 
effect. Some authors prefer cold instead of warm applications 
and injections. In this case cold water, and even ice water may 
be thrown into the rectum as a means of arresting the haemor- 
rhage ; and the same may be applied locally to the lower portion 
of the abdomen and to the pubic region. 

For the immediate relief of the collapse such stimulants as 
whisky or brandy, milk punch, or egg-nog, with inhalations of 
camphor, or ammonia may be servicable. If at the same time the 
pain is very severe, a few whiffs of the nitrite of amyl may bring 
relief and the much needed repose. The medical 
The medical treat- treatment, as stated by Jousset, is included in 
three principal indications, viz., (1) to limit 
and overcome the serous inflammation, (2) to favor the absorption 
of the effused blood, and (3) to prevent a repetition of the haemor- 
rhage. The first of these indications is to be met by the remedies 
of which I have spoken in my lecture on pelvi-peritonitis. They 
are aconite, belladonna, colocynth, rhus tox., and terebinth, to 
which may be added china, ipecacuanha, secale cor., arsenicum, 
thlaspi bursae, hamamelis and digitalis. 

Here are the notes of an interesting case to which I was called 
in consultation some weeks ago by my friend Dr. E. Gr. H. Miessler, 
of this city. 



431: THE DISEASES OF WOMEN. 

Case. — Mrs. G., aged 33 years, of bilious temperament and of 
a weak constitution, enjoyed good health until she was married, 
which was ten years ago. From a continued exposure to wet and 
cold (her lot was to assist her husband in a butcher shop) she 
contracted rheumatism, which not only caused her very severe 
pain at times, but made her lame and wretched. At the end of 
the second year of her married life she gave birth to a premature 
child, which labor occurred in the eighth month. From want of 
proper care and assistance this accident gave rise to some severe 
pelvic trouble, which resulted in sterility from obstructive dysmen- 
orrhcea and general debility. About the middle ot September I 
was called to relieve her if possible of her pain and lameness as 
she was not able to move about. All of her symptoms were of a 
rheumatic character, for which I found bryonia 3, was well indi- 
cated. The pains were worse on motion, and better at rest, with 
thirst for cold drinks, and constipation. 

Sept. 19 was called again. The following statement was given 
by the patient herself. She felt greatly relieved from her pain 
and lameness — was able to move about and do her work. On a 
cold rainy day, and while menstruating, she did her washing 
and took cold. Her chief complaints were severe excruciating 
pains in the left ovary, and in the back, across the kidneys. 
Pulsatilla and belladonna 3 were given in alternation, and hot bran- 
poultices were ordered to be applied locally. There was but 
slight fever. The next day the ovarian pains were somewhat 
relieved, but the pain in the back was more severe. It was not a 
constant pain, but paroxysmal, and seemingly aggravated by 
flatulency. There was nausea and vomiting, with a yellow-coated 
tongue, loss of appetite, thirst, restlessness and headache, tenes- 
mus, ccnstipation of the bowels. A vaginal examination revealed 
some swelling along the posterior wall of the vagina, which was 
very sensitive to the touch, the pain being made very much worse 
by straining at stool. Nux vomica and lycopodium 3, to be given 
alternately, and also an injection of warm soap-suds, but all in 
vain. 

Sept. 20. No better, but rather worse. Pulse 120 — tempera- 
ture 102° — more swelling, and all the symptoms aggravated. 

Sept. 21. There is an aggravation of all the symptoms. Pulse 
being 120, temperature 102°, the tumor being larger and more 
painful. The same treatment was continued. 

Sept. 22. The patient having had a very restless night 
despaired of her recovery, and expressed a desire to have another 
physician called in consultation, to which I willingly consented, 
and Dr. R. Ludlam was sent for. He made a careful examination 
and approved my diagnosis, that it was a genuine case of retro- 
uterine hematocele. It was thought best to hasten suppuration 
by injecting water as hot as it could be borne, and to give hepar 



PELVIC HEMATOCELE. 435 

sulph. internally. The hot water injections, which were to last 
from ten to fifteen minutes at a time, and to be repeated several 
times during the day, gave great relief. On account of the great 
pain, caused by the flatulence, and the fearful tenesmus, lycopodium, 
nux vomica, and mere. sol. were successively given. After two 
days more of suffering, a very offensive matter of a dark brown 
color escaped by the rectum, which gave decided relief. Then for 
a day the discharge was very profuse. It gradually lessened in 
quantity, but lasted about five days. As the tumor discharged its 
contents, all the morbid symptoms disappeared, and the patient 
made a good recovery. 

The surgical treatment consists in discharging the contents of 

the tumor either by incision or by tapping. The former method 

is proper and expedient only when the tumor 

The surgical treat- j m ^ ^j, accessible> The latter is the 
merit. J 

common method of discharging the cyst. In 
our day these tumors can be tapped with the aspirator much 
more safely than was possible with the old-fashioned trocar. But 
still the operation is not devoid of danger, and is strongly contra- 
indicated in certain conditions. Thus it would 

Contra-indicationsfor not b gafe Qr expedient while the e ffused blood 

tapping. ... 

continues in the fluid state, without being 
encysted, nor while the size of the tumor continues gradually to 
diminish and the patients condition to improve, nor if the source 
of the haemorrhage, being catamenial and dysmenorrhceal or 
obstructive, still remains to reproduce the difficulty. Most authori- 
ties have regarded it as an " extreme resource." 

But, if the tumor has existed for a long time, and shows little 
or no disposition to be absorbed or to disappear ; if the original 

cause of the haemorrhage in such cases is no 
^indications for tap- longer - n operation . if there is a very large 

accumulation, which is not too recent, but which 
causes great pain and pressure, with forcing pains like those of 
labor; if there are rigors and signs of suppurative fever; if the 
symptoms are those of septic infection, or typhoid in character, 
with a hyperthermic condition, there should be no delay in evacu- 
ating the tumor. I am opposed to putting it off very long, for 
when properly used it gives great relief and expedites the cure. 
Some authorities, remembering that Nature most frequently 
discharges these tumors spontaneously through the rectum, insist 
that they should be tapped from the rectal side. But this is not 



436 



THE DISEASES OF AVOMEN. 



important. We select the most dependent part of the pouch, anc£ 
discharge it with a large-sized aspirator trocar. 




Fig. 43. The aspirator. 

A safer resource in the hands of an experienced gynecologist is 
to open the abdomen, empty out the accumula- 

Laparotomy, washing . • . • i i i • i m 

and drainage in. tion, tie any bleeding vessel, remove the ovary,, 
or the wounded tube, if necessary, wash out the 
abdominal cavity and close the wound with careful drainage. 



LECTURE XXVII. 



CERVICAL METRITIS. 

-Acute Cervical Metritis ; Chronic Cervical Metritis ; Corporeal cervicitis and scanty 
menstruation. 

Of late the subject of the inflammation of the uterine cervix has 
attracted more attention than ever before. Its diagnosis and 
treatment are very far from being perfect, but the case that I shall 
show you upon the table, and my remarks upon this form of inflam- 
mation in my general clinic will give you a practical idea of this very 
important subject. For, as there will be no lack of these cases in 
your private practice, wherever you are located, it is my duty to 
familiarize you with the different forms of cervical metritis. 

ACUTE CERVICAL METRITIS. 

Case. — Mrs. , aged 35, the mother of three children, the 

youngest of which is six years old, relates the following story: 
Eight days ago, at the proper time, the menses made their appear- 
ance without any unusual symptoms. On the same morning she 
commenced a five days' job of work upon the sewing machine. 
At the close of the first days' labor the flow ceased for some 
hours, and then, after a foot-bath and a night's rest, it returned. 
On the third day there was another intermission in the menstrual 
discharge, and on the fourth clay it ceased entirely — two days 
sooner than usual. 

She now complains of headache, with slight vertigo, the face 
is flushed, the pupils are somewhat dilated, noise worries her, and 
she cannot bear the light. There are cutting, darting pains in 
the upper portion of the thighs and across the hips. These pains 
are Avorse on motion and while standing upon the feet. She also 
has a burning, bearing-down pain, within the pelvis, some stran- 
guary , and great discomfort. She is very nervous and apprehensive. 

The " touch" reveals the os uteri patulous, the cervix swollen, 
hot, dry, and exquisitely tender. She cannot bear the least pres- 
sure upon it. The womb lies very low in the pelvis, so much so 
that when she stands upon her feet it rests upon the perineum. 

Examination with the speculum shows the tumefied and tender 

437 



438 THE DISEASES OF WOMEN. 

cervix to be congested and more than twice as large as natnral T 
but there are no signs of abrasion, neither of ulceration. The 
epithelium covering its vaginal portion is intact, and there is no- 
unnatural discharge from the external os uteri. 

This is a case of acute inflammation of the neck of the womb. 
Writers describe two varieties of cervicitis — one in which the 
substance, or parenchyma of the uterine cervix 
is the seat of the inflammation (cervical metric 
tis), or areolar hyperplasia (Thomas); another in which the 
inflammation is limited to the mucous membrane that covers the 
vaginal portion and lines its canal (cervical endo-metritis). These 
diseases are so frequent and troublesome that you will need to 
study their clinical history most carefully. 

Cervical metritis is very rare in those women who have not 

given birth tcf one or more children, either prematurely or at term. 

Indeed the most powerful predisponent of this 

Rare in nulliparae. , . . 

disease is found in the changes which are inci- 
dent to the uterine cervix during the middle and later months of 
gestation. The virgin cervix is firm and fibrous, almost cartilag- 
inous in texture. Its vascularity is not at all pronounced, its dil- 
atability is scarcely sufficient to permit the ready exit of the 
menses. But the modifications which it undergoes during preg- 
nancy change the consistence of its tissues, not temporarily, but, 
in a sense, permanently. The contraction and involution which 
follow delivery do not restore the unyielding nature which is 
proper to the virginal cervix, and thenceforth we find it liable to 
diseases from which it was exempt before. 

One of the most frequent of these affections is acute cervical 
metritis. And all of its exciting causes produce a more decided 

and damaging effect if they are applied at or 
predisponent 1117 cyde a about the time of the menstrual return. It is. 

possible that this woman might not have expe- 
rienced any ill consequences from the same kind of exercise had it 
been taken at another time. But, she " did not think,' ' — a very 
common infirmity with patients as well as with their physicians — 
and therefore, she set to work the very day the flow began, intend- 
ing to persevere with it during the " period." 

Much has been said and written of the sewing-machine as a 
cause of uterine disease. I apprehend that it is the abuse, instead 



CERVICAL METRITIS. 439 

of the proper use, of the machine that works the mischief in those 
who run it. The trouble is that, with most 
utfSnl n disTa a s C e h s mes and housekeepers, it offers such a ready and expe- 
ditious means of doing the family sewing that 
they are tempted to postpone this labor until it has accumulated 
for weeks, and perhaps even for months. Then they go to work 
for days and nights consecutively, in order to despatch it, and to 
" get it out of the way." The instrument itself may be as inno- 
cent as the piano. It is this habit of playing upon it, or rather 
of working with it, continuously for hours and days together, 
that does the harm. If the same work were properly distributed, 
as our wives and daughters " practice " upon the piano — not as 
a business, but as a recreation and diversion, the result would 
doubtless be very different. In the case of those women, how- 
ever, who are obliged to sit at the sewing-machine from morning 
until night each day in the week, in order to obtain a livelihood, 
it is almost impossible for them to escape certain functional and 
organic diseases of the womb. 

Whatever tends to wound, bruise, or irritate the neck of this 
organ may, in those who are predisposed to it, give rise to cervi- 
cal metritis. Too violent exercise, as horseback 
mSritis S ° f acute cervical riding, or riding in a rough carriage or car , 
misplaced, or badly -fitting pessaries ,' too forci- 
ble and excessive coitus ; prolapsus, and the various flexions of 
the uterus , standing for too long a time upon the feet, as in the 
case of female clerks in our shops and stores, and of ladies at 
fashionable parties ; a sudden arrest of the menstrual flow ; and 
the extension of the inflammation in cervical endo-metritis from 
the lining membrane of the uterine cervix to its parenchymatous 
structure, are among the more common exciting causes of this 
disease. 

You will readily understand how it is possible for either of these 
causes to develop this form of metritis by converting the physio- 
logical injection of its structures, which is nec- 
res^i°ts e ° f operation and essary to their nutrition and also to the men- 
strual function, into a pathological congestion 
thereof. A local arrest of the circulation, a temporary sluggish- 
ness, or stasis of blood in its loose, connective, dilatable tissue, 
represents the first step in the inflammatory process. What the 



440 THE DISEASES OF WOMEN. 

result of this engorgement will be we can not say beforehand. If 
the cause is not removed and the case properly treated, the cervix 
may become the seat of chronic inflammation, hypertrophy, indu- 
ration, and possibly of scirrhous deposit. 

Acute cervical metritis is more likely to be confounded with cer- 
vical endo-metritis than with any other disease. In the former, 
the neck of the womb is swollen and tender, 

Differential diagnosis. 

not only to a light touch, but also to pressure 
upon it from within the vagina, and through the rectum ; there is 
no abrasion and no ulceration, no appearance of hypertrophied 
villi (so often mistaken for granular ulceration) and no leucor- 
rhceal discharge. The constitutional symptoms are such as attend 
upon the more severe forms of local congestion and inflammation 
in other parts of the body. There is almost always pain in the 
head, photophobia, a flushed face, and such nervous symptoms as 
those of which this patient complains. 

Fortunately the organic changes in the cervix, which are the 
sequelae of acute cervical metritis, develop so slowly that prompt 

and proper treatment may prevent the disease 

from becoming chronic, In most cases, how- 
ever, these changes take place insidiously and in a latent manner, 
so that the acute stage will have passed before the physician is 
consulted. Doubtless the frequent return of the menses serves to 
perpetuate the liability of the neck of the womb, which has once 
been inflamed, to repeated attacks, that may finally end in estab- 
lishing the chronic form of the disease in it. In those women in 
whom the cervix is unusually long, as well as in those who are of 
a relaxed fibre, cervical metritis is very apt to become chronic and 
intractable. The same is true if the disease occurs in women of 
a decidedly bilious temperament, and who may be suffering from 
old hepatic disorders. Chronic affections of the rectum, as pro- 
lapsus and hemorrhoids, sometimes retard or prevent the cure of 
a case of cervical metritis. 

Treatment. — The increased suffering which this woman experi- 
ences when she is upon her feet, suggests that she should not be 

allowed to walk about. The horizontal posture 

Postural treatment. .-, P . . 

is the first thing you should prescribe lor simi- 
lar cases. You can not expect to cure them readily if the posi- 
tion of the patient's body facilitates and necessitates a determi- 



CERVICAL METRITIS. 4.41 

nation of blood to the inflamed part. Especially should these 
patients be counseled to keep to the bed or sofa during the men- 
strual period, and for some days thereafter. They should also 
avoid all those emotional influences which might, directly or indi- 
rectly, excite the sexual system. The bladder should be emptied 
regularly, and the bowels not permitted to become torpid and in- 
active, or otherwise the intra-pelvic circulation might be so 
deranged as to prevent the best chosen remedies from having their 
desired effect. 

If, in a given case, there is reason to believe that any of the 

causes already named has occasioned the attack, that cause must 

be removed. And you should act promptly. 

Remove the cause. T _ . . .. 

Learn the source of the mischiet and remove it 
as soon as possible, else the most proper and appropriate time for 
curing the case, or at least for preventing it from developing into 
the chronic form of the disease, will have passed before you have 
accomplished anything. 

As the result of an abundant experience, I am persuaded that 
in these cases of engorgement of the cervix uteri, with incipient 

inflammation of its deeper-seated tissues, " pre- 
•cure revention be " er than mention is better than cure." Hygiene should 

go hand in hand with Therapeutics. It would 
not be sufficient to give this woman belladonna, or any other rem- 
edy, and dismiss her without specific instructions concerning her 
habits of life, of exercise, and exposure. It is just here that our 
knowledge of special physiology and of special pathology will 
render us the most important aid. It may fail to suggest the rem- 
edy for the symptoms complained of, but it will not fail to suggest 
what, in such a case as this, is vastly more important. 

It might involve a species of suicide for this patient to persist 
in running the sewing machine. She should not ride or walk very 

far or frequently. A journey from Chicago to 

New York, before her symptoms are relieved 
and the next menstrual period safely passed, might render her an 
invalid for months or even for years. And so also of croquet, of 
ironing, sweeping, or prolonged standing upon the feet, whether 
for pleasure at a party, or for profit in a store or in school. Any 
menstrual irregularity should be remedied. Sexual congress should 
l>e prohibited. Pessaries and every species of artificial support, 



442 THE DISEASES OF WOMEN. 

whether within the vagina or around the body, are positively and 
decidedly mischievous in this class of cases. The same is true of 
the use of cold and astringent injections thrown into the vagina, 
and of most of the lotions and ointments that are applied in case 
of haemorrhoids. 

If you can properly attribute the attack to traumatic injury, 

there will be no harm in prescribing a vaginal injection, consisting 

of the tincture of arnica, glycerine, and tepid 

Local measures. i i i ■ r • i • ^ 

water, in case she has nsemorrnoids, with 
venous discoloration of the vagina, or a varicose condition of the 
veins of the lower extremities, it is best to substitute •hamamelis, 
for the arnica. Simple glycerine and water, one part of the former 
to five of the latter, will sometimes allay the burning heat and 
pain within the pelvis. I have occasionally witnessed the best, 
effects from Dr. Sims' method of applying pure glycerine directly^ 
to and about the cervix by means of a cotton or sponge tampon 
which is saturated with it. In one of my cases it certainly brought 
away half a teacupful of serum with which the swollen and pen- 
dulous cervix had previously been engorged. It may be possible 
by some such simple and harmless expedient to prevent what 
might otherwise develop into chronic cervical metritis. 

The internal treatment should be regulated by the obvious, 
symptoms peculiar to the individual case for the cure of which you. 
are consulted. This woman will take of bella- 
donna 3d, a dose every three hours. When her 
symptoms are somewhat improved, it may be repeated once in six 
hours. Let her come again next week. 

In some of these cases, whether complicated with other forms; 
of pelvic inflammation or not, and where tho 

The hot rectal douche. - .11 , i n i 

suffering is very acute, the hot rectal douche 
recommended by Dr. Chad wick, of Boston, is an excellent means 
of relief. The water used may be as hot as the hand can bear, 
and before it is thrown into the rectum, the finger should be passed 
into the vagina with its palmer surface toward the cocyx. As 
soon as you begin to feel the lower pouch filling up, you should, 
wait a little, but without withdrawing the nozzle of the syringe. 
In this way from one to four pints of water may be injected with- 
out exciting an immediate action of the bowels. The patient 



CORPOREAL CERVICITIS, ETC. 443 

should keep quiet for half an hour, and it is possible that the water 
may not pass away again for an hour or two. 

CHRONIC CORPOREAL CERVICITIS. CHRONIC CERVICAL METRITIS. 

Case. — Mrs. Emma H. , aged 26, Irish, is of sanguine 

temperament, has had three children and two miscarriages, the 
last of which she induced herself six months ago. The menses 
have always been profuse, and accompanied with great pain. At 
present she complains of pain in the left hypogastric region which, 
at times, extends to the pit of the stomach. She also says she 
has pains through the womb. The bowels are habitually costive. The 
appetite is poor. Micturition is difficult, and the urine carries a 
heavy deposit of urates. She also has leucorrhcea, which is both 
cervical and vaginal. . . 

Physical examination shows the uterus to be three and a half 
inches in length. The cervix is engorged, thickened and swollen 
in the direction of its circumference. Its diameter measures 
nearly two inches. It is ■ smooth and firm to the touch. The 
introduction of the sound, although not at all difficult, occasioned 
great pain. There is nothing discoverable about the neck of the 
bladder or the urethra to account for the painful micturition. 

She was first placed on belladonna 3 once in two hours. The 
cotton tampon saturated with pure glycerine, was to be intro- 
duced every evening and worn through the night.. This treat- 
ment, local and general, promptly relieved the engorgement and 
tumefaction of the uterine cervix, and her general condition was 
very much improved. Since that time, however, she has treated 
herself and our clinical assistants, to a series of hysterical mani- 
festations, of which the following is a list : 

1st. Gastralgia, which continued at intervals for three days. 

2d. Retention of urine — which she passed easily enough when 
left to herself — lasted one week. 

3d. Paralysis of the right arm for three days, and 

4th. Pseudo-pleuritic pains that continued for twenty-four 
hours. 

Our patient was brought into this institution from a neighbor- 
ing hospital where, she says, her case was decided by the phy- 
sician to be one of uterine cancer. I do not credit her story, and 
yet it may be a true one. For excepting what the doctors some- 
times say of each other, no kind of testimony is so unworthy of 
trust as that which patients bring us concerning the views of 
other physicians, and the treatment to which they have already 
been subjected. 



444 THE DISEASES OF WOMEN. 

Symptoms — This is a case of chronic cervicitis, or of cervical 

hyperplasia. For some reason, most probably on account of the 

abortions which she has suffered, such inter- 

Mechanical symptoms. . . - . . 

stitial changes have taken place within the 
uterine neck as to result in its enlargement and hypertrophy. 
Its measurements are very much increased, so that, within the 
pelvis it acts like a foreign body, or a tumor, causing suffering in 
other organs, and making the patient wretched. It presses 
against the urethra in such a manner as to give great pain on 
passing water ; upon the rectum so as to cause the bowels to be 
obstinately bound ; and is sufficient to maintain a constant leu- 
corrhoeal flow. 

•Other symptoms which usually attend upon this affection are 

pelvic and sacral pains ; prolapse of the womb, which is dragged 

toward the vulva by the increased weight of 

Direct and reflex symptoms. . 

its lower segment; dyspeptic troubles, as 
vomiting, loss of appetite, gastralgia, loathing of food and caprices 
of appetite ; and inability to walk without great effort, pain and 
fatigue. The incidental nervous disorders are more prominent 
than characteristic. Hysterical symptoms are an almost certain 
outgrowth of this particular lesion. Reflex ovarian irritation is 
also very common, and pains in the left hypogastrium, such as 
this woman complains of, are almost always present. 

Menstrual disorders are frequent. Some of these patients have 
amenorrhcea. In many cases there is unusual pam and difficulty 

in the commencement of the "period," which 

Menstrual disorders. . • i i • i i p i 

is occasioned by a partial closure 01 the cervico- 
uterine canal. But when that obstacle is overcome, the cervix 
being so very much engorged, the flow becomes excessive and 
perhaps long-continued. It often arises from excessive or impro- 
per exercise or travel at the month. 

The neck of the womb is so tender to the touch that sexual 
intercourse is intolerable. In some cases of insuperable aversion 
to the act, which you will meet with in private 
practice, you will find that this condition of 
the cervix exists, Many patients with this form of cervicitis 
complain of burning pain within the pelvis. This pain is usually 
aggravated by exercise, as in standing, riding or walking. With 



CORPOREAL CERVICITIS, ETC. 445 

the swollen cervix against the vaginal walls sometimes occasions 
extensive ulceration of its investing mucous membrane. 

Nature and Cause. — This disease consists essentially in a 
hypertrophy of the cellular tissue of the uterine cervix. And 

this hypertrophy, or hyperplasia, as Dr. 

Thomas prefers to style it, almost never occurs 
excepting in those who have been pregnant. It is a post-puer- 
peral affair. It may follow delivery at term, but is more likely to 
result from an arrest of development consequent upon abortion. 
In many cases it supervenes the artificial induction of miscar- 
riage, the traumatic injury sustained seeming to add to the risk 
of its resulting as a sequel. 

It may be either the cause or the consequence of dysmenor- 
rhcea. In " bilious climates" it is indirectly connected with 

hepatic disease. In this class of cases the 

From bilious complication. . i -i • i 

uterus acts as a diverticulum tor the blood which 
should circulate more actively through the portal system. The 
connective tissue of the cervix becomes engorged, and an exces- 
sive development of the uterine neck is the consequence. The 
cause acts and re-acts. You will be on the alert for this condi- 
tion of things among multiparas in malarious districts. 

Diagnosis. — A few symptoms, carefully considered, will gener- 
ally enable us to differentiate between this disease and cancer of 
the uterine neck, which is usually of the scir- 

From uterine cancer. . 

rnous variety. I am pretty confident that, in 
this case, the swelling of the cervix is not due to scirrhous de- 
posit, because it is smooth and regular in outline and feels like a 
fibrous tissue. If it were cancerous, the outline would be irregu- 
lar, nodulated, and bosselated, and it would feel hard and carti- 
laginous. Cervical metritis is almost always a sequel to preg- 
nancy and to labor. It bears no especial relation to the climacteric. 
Cervical cancer is not at all infrequent in nulliparae, and is most 
common at the "change of life." In the former, no matter how 
much the organ is swollen or displaced, it is mobile. In the 
latter, it may be fixed and immovable. In cervical metritis there 
is no evidence of a particular cachexy, while in cervical cancer 
such a dyscrasia is, sooner or later, manifest. In cervicitis there 
is no tendency to deep-seated ulceration, with destruction of 



446 THE DISEASES OF WOMEN. 

tissue and haemorrhage ; in cancer, such a tendency is very 
marked. 

But, even with the greatest care, it is not always possible to 

distinguish between these two diseases, more especially in the 

non-ulcerated state of uterine cancer. I have 

A new diagnostic test. . 

several times resorted to an expedient that has 
helped me to settle the diagnosis between them. You will do no 
harm by trying it. It is simply to use the cotton tampon satu- 
rated with pure glycerine, just as it was employed in this case. 
If the enlargement is due to plain, uncomplicated cervicitis, the 
depletion by means of the glycerine will soon lessen the size of 
the uterine cervix very perceptibly. If, however, the swollen 
state of the cervix arises from cancerous infiltiation, or from an 
interstitial fibroid, the glycerine will not sensibly diminish its 
bulk. If this simple test had been applied in the case before us, 
my unknown predecessor would not have decided this to be a 
case of uterine cancer ; for now the cervix is nearly normal both 
in size and texture. 

• The increased depth of the womb, the liability to haemorrhage, 
to endometritis, to uterine displacements, and to coincident peri- 
tonitis, which belong to chronic corporeal me- 
mS?t!s nosis from corporeal tritis, and not to corporeal cervicitis, will 
serve to separate these two diseases. In some 
cases they succeed each other, and again they co-exist. 

Prognosis. — This disease may continue indefinitely. Its course 
and termination will depend upon the nature and severity of the 
disorders with which it is complicated. It may decline at the 
climacteric, or possibly develop into a more serious form of or- 
ganic disease. In a reflex manner it may cause the gravest lesions 
of the heart, the lungs, or of the nervous centers. Frequent 
abortions render it more chronic and intractable. If the patient 
is ill in other respects and incapacitated from exercise, the cure 
is more doubtful. 

Treatment. — It is quite as important to prescribe the proper 
posture for this class of patients as it is in case of acute cervical 
metritis. Keep them in a horizontal or reclin- 
ing posture, and off their feet,, at the month 
especially. Shopping, visiting, party-going are as injurious as a 



CORPOREAL CERVICITIS) ETC. 447 

journey by rail, or an excursion on horseback. Such a patient 
should let her sewing-machine rest, and her servants take care of 
themselves. 

If there is obstructive dysmenorrhoea, remove the cause and 
relieve the consequent engorgement of the cervix. If she has 
intermenstrual dysmenorrhoea, cure it. If the 
flow is too scanty, try and prompt it to be more 
free. If the rectum is paralyzed, or the bowels are badly consti- 
pated, she may be relieved when these conditions are set aside. 
She should be especially careful not to do anything before, during 
•or directly after the flow that can by any possibility complicate 
the case and increase the cervical hypertrophy. 

If there are " bilious " symptoms remember that they are likely 
to afford the most prominent and cardinal indications for £he rem- 
edy or remedies. Podophyllin, mercurius, chamomilla, bryonia, 
tiux vomica, china, natrum mur., nitric or nitro-muriatic acid, or 
some similar remedy, may be specifically called for. 

Other remedies that I have found especially useful are bella- 
donna, lachesis and apis mellifioa. Some of the 

Bell., lach. and apis. 

best cures that 1 have ever made have been 
performed with these three remedies in this class of cases. 

Locally the same treatment as already recommended for the 
acute form of this disease is equally suited to the chronic vari- 
ety. The cotton tampon saturated with glyc- 

Local adjuvants. \ r . iDj 

erme can do no possible harm, will not interfere 
with the action of internal remedies, and may do a positive good. 
After the first application it can be prepared, introduced and re- 
moved by the nurse or the patient herself. I generally recom- 
mend that it shall be used two or three times per week, according 
to circumstances. 

CORPOREAL CERVICITIS AND SCANTY MENSTRUATION. 

Case. — Mrs , has a urinary trouble, which is aggravated 

about the time of the flow, the menses are regular but scanty. 
The trouble began two years after the birth of her child, which 
w r as about six years ago ; she has never had a miscarriage ; she is 
obliged to pass the urine often, it is painful and scanty, and there 
is a thick sediment; sometimes there is but little pain, but it will 
be increased if her feet are cold ; there is some strangury, but no 
involuntary flow ; riding in the cars increases the urinary difficulty. 



448 



THE DISEASES OF WOMEN. 



On local examination, the os was found much swollen and of a 
purplish hue, with a well defined vesicle on the anterior lip which 
was filled with serum. The cervix was elongated, red, and of 
sugar-loaf form, but there was no abrasion or ulceration, and no 
leucorrhcea. There is no flexion or sub-involution of the uterus. 
Tartar emetic 3, three times a day. 

This woman first presented herself at our general clinic. She 
has since submitted to a careful local examination in the sub- 
clinic, and »her case is now a clear one. She has corporeal cervicitis,, 
the principal enlargement of the cervix being at its upper portion. 
Those of you who saw it in the field of the speculum will remem- 
ber how it looked. You will also recall my remark'that, since she 
had not had menorrhagia, but really suffered from scanty and diffi- 
cult menstruation, it was impossible for her to have either chronic 
metritis,* or sub-involution of the womb. And you remember that 
when I introduced the sound it passed to the depth of two and a half 
inches only, which fact confirmed my statement. 

But, how can corporeal cervicitis occasion a scanty flow of the 
menses? Manifestly by narrowing the cervical canal and thus 
partially obliterating its outlet. And the pres- 
sure of this same tumefied cervix upon the neck 
of the bladder causes the strangury. 

The fact that this latter symptom did not depend upon any form 
of uterine deviation was demonstrated to you by the direction 
which the point of the sound took when it 
entered the womb, and which it afterwards 
kept. 

The rational treatment for scanty men- 
struation in this particular case consists in 
the adoption of measures for the cure of 
the concentric hypertrophy of the cervix. 
The indications are not 
changed because, in this 
particular instance, the lesion is chiefly 
limited to the upper, or the abdominal 
portion of the neck of the womb. Hot 
water irrigation (See Fig. 44,) rest in the re- 
cumbent posture, especially at the month ; keeping the bowels 
regular, and the bladder from becoming distended ; the avoidance 
of excessive sexual excitement, tight lacing, or too prolonged 



Query. 




Treatment. 



Fig. 44. Hall's Syringe. 



CORPOREAL CERVICITIS, ETC. 



449 



standi 112:, and the passage of the sound, or the trial of slight and 
careful dilatation of the cervical canal almost directly in advance 
of the flow, are measures. 




Tartar emetic. 



Fig. 45. Peaslee's uterine stems. 

This latter indication can be met by the passage of the sound or 
of graduated bougies in the form of Peaslee's dilators. 

Clinical experience teaches that in this kind of a case, the indi- 
cations are peculiar. The symptoms detailed by this woman are 
as real as those of pneumonia or of rheumatism, but they depend 
upon a mechanical cause, and will persist while that cause con- 
tinues to be applied. The structural lesion furnishes the chief 
indications for the treatment, because, without this lesion, there 
would be no symptoms that were sufficiently distinctive to tell us 
what the trouble was, neither what the remedy should be. I pre- 
scribed tartar emetic being fully satisfied of its 
power to reduce the hyperplasia in this benign 
and localized form of uterine inflammation. It may not be suffi- 
cient of itself to cure the case, but it will give us a start in the 
right direction, and you should not forget that the first step 
towards a cure, like the beginnings of disease, is often the most 
important part of it. 

During the past summer (1880) I had at one time six cases of 
this disease under treatment in my sub-clinic. These cases were 
carefully examined from week to week in the presence of the class. 
All local treatment whatever was withheld, and the most careful 
observations were made and noted in each and every case. They 
took no other remedy than tartar emetic, and the effect was so 
perceptible that every member of the class, as well as a number of 
physicians who were present from time to time, was satisfied with 

the result. 

33 



450 THE DISEASES OF WOMEN. 

Where this inflammation is benign, and the infiltration of the 
cervix with serum that is loosely organized, constitutes the whole 
of the local difficulty, the case is in some sort the counterpart of the 
hepatized lung in pneumonia. This was what Spiegelberg 
recognized when he recommended the sponge tent as a means of 
diagnosticating simple corporeal cervicitis from cancerous infiltra- 
tion of the cervix, and this was my idea in advising the internal 
use of tartar emetic tor the resolution of the hypertrophied cervix, 
when it was traceable to a non-specific inflammation. I have now 
been in the habit of using it in similar cases for more than ten 
years, and although it is not always curative, it seldom fails to be 
of essential service, especially in conjunction with the topical use 
of glycerine, or of hot-water irrigation. 

There is a clinical distinction between uterine hyperplasia, 

whether it be of the cervix or of the body of the 
uten ?ub?mvo r iSdon! and womb or both, and uterine sub-involution. The 

former, especially, if it is limited to the cervix, 
is almost always accompanied by painful and scanty menstruation ; 
while the flow in sub-involution is always excessive, and, unless it 
is accompanied by endo-metritis, is rarely painful. In exceptional 
cases there is no doubt that these two conditions coexist. When 
you are in doubt, there can be no impropriety in prescribing secale 
cornutum in the second or third decimal attenuation, and carefully 
observing the effect that is produced upon the size and texture of 
the cervix as well as the depth of the womb. 



LECTURE XXVIII. 

CHRONIC CERVICAL ENDOMETRITIS, OR ENDO-CERVICITIS. — UTER- 
INE LEUOORRHGEA. 

Endo-cervicitis; its cause, symptoms, diagnosis, prognosis, and local and general treat- 
ment.— Case. 

Inflammation of the mucous membrane lining the uterine cervix 
is especially interesting because of its clinical relation to what is 
commonly known as uterine leucorrhcea. This patient came under 
our care six weeks ago. She is now almost well, and I present 
her as an illustration of the importance, nay, the absolute neces- 
sity, of a correct diagnosis as a condition of cure in some of these 
cases, and for the purpose of showing you that the simplest reme- 
dies are sometimes the most efficacious. Her clinical history, 
as recorded on her admission, is as follows : — 

Case. — Mrs. , 28 years of age, the mother of two chil- 
dren, has been an invalid for two years past. Her ill health dates 
from her last accouchement, which was normal in all respects. She, 
however, "got up" very slowly, and was weakly during lactation. 
She still nurses her child, which is a big, hearty boy ; and being 
obliged to take the entire care of him, she holds and carries him 
most of the time. She has not menstruated since her confinement. 

She complains of aching in the loins, a dragging sensation about 
the hips, which extends to the thighs, and bearing down pains and 
pressure within the pelvis, u as if everything would be forced 
from her." This latter symptom is worse when she rises to her 
feet from the chair or couch. She also has a leucorrhceal dis- 
charge, which is thick, creamy, and sometimes more watery and 
copious. The freer this flow the greater her debility and prostra- 
tion, and the more severe and distressing the pain in the back. 
Upon arising in the morning this discharge is often so profuse as 
to cause her to be faint, to destroy her appetite, and to incapaci- 
tate her for her household duties. She finds it impossible to stand 
more than a few minutes at a time, and can not walk but a short 
distance without being very much fatigued. She enjoys a short 
ride, providing the carriage is easy and the road is not rough. 

At times she has a burning pain which, she thinks, is in the 

451 



452 THE DISEASES OF WOMEN. 

mouth of the womb. Intercourse is almost intolerable. The 
bowels are badly constipated ; the appetite poor and capricious, 
with more or less of nausea and loathing of food, especially in the 
morning. Her eyes are so weak that she can not read or sew more 
than five or ten minutes at a time without pain, indistinct vision, 
and lachrymation. 

The touch reveals a tumefaction and tenderness of the cervix 
uteri. The womb lies very low in the pelvis. The external os 
uteri is patulous, and its lining membrane everted. A thick, albu- 
minous mucus was taken directly from the can'al of the cervix and 
subjected to microscopical examination. There is no visible ulcera- 
tion, although she has been treated by three physicians for that 
disease. The neighboring organs appear to be healthy. 

I have already spoken of cervical metritis, or inflammation of 
the parenchyma of the uterine cervix. The case before us is 
one in which the lesion is limited to the mucous membrane that 
lines its canal. It is styled cervical endo-metritis, or endo-cervi- 
citis, to distinguish it from corporeal endo-metritis, internal metri- 
tis, or inflammation of the proper uterine mucous membrane, 
which is found within the cavity of the womb. For while you 
would naturally suppose that these two affections would often co- 
exist, the fact is that they are almost as distinct and as little 
related to each other as are bronchitis and bona fide pneumonia. 

Those of you who are not practically familiar with this disease 
may be disposed to question whether such a limited extent of in- 
flammation could really induce very serious or 
Extent of the cervical persistent svmptoms and ill health. The ute- 

mucous membrane. J- o -T 

rine cervix is only one and a quarter to one and 
a half inches in length. But the mucous membrane that lines its 
cavity presents a very considerable surface. Its rugae, or plicated 
folds, are numerous ; it is reflected over the arbor vitas uterinus, 
and dips down into each of the little glands within the 
cervix, of which, according to Dr. Tyler Smith, there are as many 
as from two to three thousand. In an ordinary case of endo-cer- 
vicitis, therefore, a larger extent of mucous membrane is inflamed 
than you would at first have supposed possible. 

And not only is this lesion an extensive one. The necessary 
implication of the glandular apparatus develops a disorder of se- 
cretion which depletes from the patient's general 

A glandular lesion. , , , r. 

strength, complicates the case, adds to the sut- 



CEVRICAL ENDOMETRITIS, ETC. 453 

fering and retards the cure. Every well-marked example of endo- 
cervicitis is accompanied by a more or less copious and intractable 
leucorrhcea. And, although it does not come from the cavity of 
the womb, this discharge is commonly regarded as uterine. Hence, 
a majority of writers treat of this cervical leucorrhcea, which is a 
contingent and consequence of inflammation within the cavity 
of the cervix, and exterior to the os internum, as uterine catarrh. 
As applied to this disorder the term is a misnomer, and calculated 
to mislead. For there is as great a difference 
notTSl iTtlrlh.^ 1S between the character of the now in true ute- 
rine catarrh, and in proper cervical leucorrhcea, 
as there is between the rusty sputa of pneumonia and the mucoso- 
Duriform secretion which is stained with blood in bronchitis. 

Labor, whether in abortion or at term, is indirectly one of the 
most powerful predisponents of cervical endo-metritis. The 
changes which the womb undergoes after deliv- 
ery, and which are designed, through the process 
of involution, to restore it as nearly as possible to its original size 
and form, may occur so imperfectly, or so irregularly, as to leave 
that organ in a very unnatural state. In this condition of sub- 
involution, its various tissues, including the 

A sequel of labor. . . 

mucous membrane withm the cervix, are prone 
to become inflamed. It is for this reason, as in the case before 
you, that endo-cervicitis often dates from delivery. When a pa- 
tient tells you that, since the birth of her last child, she has suf- 
fered from symptoms which are the counterpart of those of which 

Mrs. complained, you will have a strong presumptive sign 

of her disorder. A careful examination locally will either confirm 
or disprove your suspicions. 

The scrofulous cachexia also predisposes to this form of uterine 

inflammation. It could not be otherwise, when 

Scrofulosis. 

so important a part of the secretory apparatus 
is implicated. The same is true of the return of the menstrual 
<rycle. The physiological afflux of blood to the uterine cervix, 

and especially to the vascular membrane lining; 

Menstruation. . 

its cavity, may develop into a state of hypere- 
mia, and so derange the process of nutrition as to establish a gen- 
uine inflammation. Dysmenorrhcea, too frequent, tardy, scanty, 
or irregular menstruation, tend in the same direction. 



454 THE DISEASES OF WOMEN. 

The tuberculous diathesis is also a powerful predisponent of cer- 
vical endo-metritis. Depraved nutrition, from whatever cause? 
too prolonged lactation, rapid child - bearing, 

Tuberculosis. * . ° ' r . . to ' 

hereditary feebleness 01 constitution, and habit- 
ual strain of the mental faculties, if it is of a depressing character,, 
belong to the same list of causes. 

My observation leads me to remark that there is still another 
cause which should be included in this category. I allude to the 

influence of what is known as a " bilious cli- 

Biliary disorders. . 

mate. Wherever hepatic disorders prevail to 
any considerable extent, as in malarious districts, we find a strong 
tendency to this variety of uterine inflammation. Organic and 
functional diseases of the liver embarrass the circulation of venous 
blood through the pelvic viscera. In a climate in which every 
kind of morbid state is stamped with the impress of "biliousness," 
this cause is constantly at work, and the step from congestion to 
inflammation of the cervix uteri is so short a step that it is very 
easily taken. Multitudes of women have cervical endo-metritis 
from this indirect cause alone. In confirmation of this view we 
find that, next to the large class of scrofulous subjects who suffer 
from it, women with dark hair and complexion, and black eyes, 
that is to say, who are of a bilious temperament, have this disease 
most frequently, and in its most intractable form. This is an item 
which those of you who are to locate in the South and West will 
do well to bear in mind. 

The exciting causes of this disease are very similar to those 

which often give rise to cervical metritis. A sudden arrest of the 

menstrual flow, dysmenorrhea, cold wet feet 

Exciting causes. , .,,. -iii 

and damp clothing, tight lacing and the wear- 
ing of heavy skirts that are hung at the waist, violent exercise 
at the month, too forcible and intemperate coitus, the retention 
of a portion of the secundines after a miscarriage, the use of 
harsh injections to prevent impregnation, or of harmful instru- 
ments to induce abortion, ungratified sexual desire, as in nym- 
phomania ; uterine displacements ; obstinate constipation with 
paralysis or stricture of the rectum ; ovaritis ; gonorrhoea : rough 
travel in a carriage, the cars, or upon horseback, prolonged stand- 
ing upon the feet, and the wearing of ill-adjusted pessaries, are the 



CERVICAL ENDOMETRITIS, ETC, 455 

most common of these causes. Exceptionally, in corporeal endo- 
metritis, there is an extension of the inflammation from the cavity 
of the womb downwards into the canal of the cervix. This 
almost never occurs, unless it be in the puerperal state, in which 
case the endo-cervicitis is a sequel of the endo-metritis proper. 
In vulvo-vaginitis, whether it be specific or not, the inflammation 
may finally invade the cervical canal and extend as far as the 
internal os uteri. But these cases are comparatively rare. 

A mild, and in many instances a self -limited form of cervical 

endo-metritis, is sometimes met with during the prevalence of an 

epidemic influenza. You have seen several 

From Epidemic Influenza. . . . . . 

cases ot this kind m our Clmique during the 
present winter. Such attacks may be either primary or secondary. 
They sometimes alternate with catarrhal inflammation of other 
mucous passages, as, for example, the nares, the throat, and the 
bronchial tubes, and perhaps also of the alimentary mucous mem- 
brane. In women of a scrofulous, or tuberculous cachexia, as 
well as in those who are greatly debilitated from other causes, an 
incidental cervicitis of this kind is very likely to become chronic. 
The most prominent and persistent symptom (in a well marked 
case of this disease) is the leucorrhcea. It is the first abnormal- 
ity to attract the patient's attention, and the 
one above all others which a majority of prac- 
titioners are most anxious to relieve and to remedy. It usually 
begins with a slight increase of the normal healthy mucus from 
the cervix, which is observed to be most abundant a day or two 
in advance of the menstrual flow. Or it may follow menstruation, 
and continue for some days after the cessation of the catamenial 
discharge. Sometimes it is intermitting in character, being 
brought on by violent exercise or excitement at any time during 
the intra-menstrual period. The more chronic its nature, the more 
copious and exhausting it becomes. It may be creamy, viscid, 
highly albuminous, and inspissated in character. After a longer 
or shorter period, which varies in different individuals, the dis- 
charge becomes habitual and constant. Whenever the patient 
assumes the upright posture there is a sensible escape of this 
secretion from the cervix uteri. When she arises in the morning, 
after lying in bed all night, this flow may even be profuse, as it 
was a little while ago in the case before you. If it is bloody you 



456 THE DISEASES OF WOMEN. 

will remark that the blood is not thoroughly mingled, or incor- 
porated with the mucus — as it would be in case of a muco- 
sanguineous discharge from the uterine cavity. 

When the follicular inflammation within the cervix uteri is 
become deep-seated and chronic, more especially if it occurs in 
scrofulous subjects, the hyper-secretion is altered in character. 
Examination with the speculum discloses a string of tenacious, 
transparent, ropy mucus, hanging from the external os uteri into 
the vagina, and in exceptional cases, even from between the labia 
majora. Dr. W. Tyler Smith compares the appearance of this 
secretion from the cervix to that of soft soap. " It seems as if 
the alkali of the discharge combined with the fatty and albumin- 
ous element, to form a saponaceous compound.''* Farther on in 
the course of the disease, and even although there may be no 
abrasion of the os uteri, and no ulceration, pus-corpuscles are 
added, and the discharge becomes muco-purulent. In most cases, 
however, it is puriform instead of purulent. It 

The puriform discharge. . -, n , in* • i i •• 

is seldom that the now is acrid and excoriating 
in character, unless she has ulceration of the womb ; or the in- 
flammation is specific, as, for example, diphtheritic, or syphilitic, in 
its nature ; or the tone of her general health is very low, by 
reason of debilitating diseases, such as stomatitis materna, haem- 
orrhage, inanition, and a consequent deterioration in the quality 
of the blood. 

All of which leads to the inference that this form of leucorrhoea 
should properly be regarded as a symptom, and not as a disease 

per se. In this respect it ranks with a cough, 
symptom UCOrrhcEa merely a a haemorrhage, a dropsy, or a diarrhoea. When 

you take the discharge directly from the os 
uteri, and examine it in the field of the microscope, it presents 
the appearance shown in this diagram. Here are cylindrical 
epithelial cells, mucus-corpuscles, pus-corpuscles, blood globules, 
and fatty particles. These are found floating in an alkaline 

plasma, which vehicle is furnished by the cer- 
varying characters of the v j ca i gi anc [ s> D r# Tyler Smith observed that 

flow. © «/ 

the clearness or the opacity, as well as the vis- 
cidity of the discharge, its creamy, soapy, gelatinous or ropy appear- 

* The Pathology and Treatment of Leucorrhoea, by W. Tyler Smith, M. D M etc., 
Philadelphia, 1855, page 64. 



CERVICAL ENDOMETRITIS, ETC. 457 

ance, and indeed all of its physical characters depend upon the alka- 
linity or the acidity of the secretion with which it is mingled. The 
acid mucus secreted in the vagina changes the quality of the leu- 
corrhceal fluid poured out from the cervix uteri, as decidedly as 
it does that of the blood which escapes from the same channel in 
ordinary menstruation. I think it very important for you to 
remember this fact. 

You will not understand me to say 7 that all cases of this form 

of leucorrhcea depend npon cervicitis. By no means. There are 

other causes, such as obliquities of the uterus, 

Cervical leucorrhcea from ^[ 1Q p resenCe f foreign OTOWtllS, ulceration of 

■other causes. ± o o 

the os uteri, granular degeneration, ovaritis and 
kindred affections even more remote, and which operate in a 
reflex way, that sometimes originate and perpetuate this discharge 
by stimulating an undue activity of the glands within the cervix. 
For the present I must defer their consideration. 

The dragging sensations about and within the pelvis are not 
always so marked and severe in this form of cervical inflammation 

as they are in cervical metritis. For in endo- 

Pelvic pains and suffering. ...... -, n , , . 

cervicitis the neck ot the womb is not neces- 
sarily so tumefied and tender ; and we find that the contingent 
distress and pain in the sacral and lumbar regions vary with 
the quantity and quality of the leucorrhceal flow, rather than 
with the size of the cervix. Something depends, however, upon 
the state of the patient's strength, the duration of the disease, 
her ability to withstand suffering, or her tendency to exag- 
gerate and overstate the kind and degree of her pain. She 
is very apt to complain of bearing down sensations, symptoms 
of prolapse, forcing of the pelvic viscera towards the vulva, and 
not infrequently of rectal aching and tenesmus whenever she 
stands upon her feet. Under these circumstances there is an 
aggravation of the symptoms from motion, pressure, coughing, or 
sitting down. 

These patients frequently complain also of burning sensations, 

which are located either within the vagina, at the; mouth of the 

womb, or in the ovarian region. Sometimes 

Burning sensations. . -i • i -\ -, 

the cervix is so displaced and tender that inter- 
course is very painful. More rarely, however, the unnatural con- 
dition of the parts causes an increased sexual desire, which the 



458 THE DISEASES OF WOMEN. 

patient feels must be gratified, even though it be at the cost 
of subsequent suffering. Straining at stool, or in urination, may 
cause a flow of mucus from the cervix, and even from the vagina. 
The bowels are almost always constipated, although in some cases 
there is an alternation of constipation and diarrhoea. The bladder 
is more or less implicated, and cystitis, vesical tenesmus, dysuria 
and retention are by no means infrequent. 

Either as a cause or a consequence of the local lesion, the 

digestion is impaired, the nervous system undermined, and the 

general health borne down. Among the lower 

Constitutional effects. 

orders especially, such patients are very 
wretched. They are martyrs to vice, ignorance and self-depend- 
ence, to their children and families, to their own improvidence, 
and not unfrequently to the incompetency of their doctors. 

A considerable proportion of cases of endo-cervicitis are char- 
acterized by impaired vision, or rather by weakness of the eyes 

and inability to use them. This is true not 

Weakness of the eyes. . . 

alone 01 inflammation ot the cervical mucous 
membrane, but of other diseases of the uterine neck, and perhaps 
of the ovaries also. For there is an inexplicable sympathy be- 
tween the inferior segment of the womb and the eyes. I have 
treated a case of incipient amaurosis which was entirely and 
promptly relieved by the removal of a small mucous polypus that 
was found hanging from the external os uteri. Women have in 
almost numberless instances complained to me of pain, aching and 
weakness of the eyes immediately after the application of even 
the mildest lotions directly to the cervix. It is not at all unusual 
for this symptom to follow copulation temporarily, and in case 
of immoderate indulgence of the sexual appetite, to become 
chronic and perhaps incurable. The patient before you had these 
symptoms in a marked degree, and just in proportion as the ute- 
rine irritation and inflammation have been relieved in her case,, 
has the weakness of vision and its attendant symptoms improved. 
My friend Prof. Yilas, the oculist, informs me, however, that 
such symptomatic derangements of vision are apt to remain after 
the primary trouble with the uterus has been cured. 

Upon making an examination with the speculum in a case of 
endo-cervicitis, if the woman has ever been pregnant, you will 
almost certainly find the cervix uteri somewhat swollen, the os 



CEKVICAL ENDOMETRITIS, ETC. 45 9 

patulous, and, if the leucorrhceal flow has been copious or long 
continued, the mucous lining of the canal ol 
s P ?culum ation whh the the cervix everted. In the virgin, however, 
and in those who have never conceived, as well 
as in very mild and recent cases, the tumefaction, the relaxed and 
open os uteri, and the hernia of the cervical mucous membrane may 
be lacking, and yet other equally reliable signs may lead you to 
diagnosticate the case as one of cervical endo-metritis. In other 
words, the inflammation in this case is limited to the cervical 
canal, bounded above by the internal os, and below by the exter- 
nal os uteri. I am convinced that endo-cervicitis is much more 
common among young unmarried women than it is generally sup- 
posed to be. 

In the latter class the vaginal portion of the cervix is rarely 
inflamed. Its investing membrane is not congested, neither is it 
hot, dry, or especially tender. But in confirmed cases, occurring 
in women who have borne children, you will observe that the 
mucous membrane about and within the os uteri is in a state 
of hyperemia and of evident inflammation. The nearer the men- 
strual period the more these parts will be congested, and the more 
open and dilatable the os tineas. 

In considering the diagnosis of this disease we are led to remark 
that the most mischievous results have followed the confounding 
of inflammation with ulceration and induration 
of the neck of the womb. Dr. Bennett, for 
example, believes them to be consecutive and inseparable, and, 
therefore, treats of them as synonymous, if not absolutely identi- 
cal. Errors in diagnosis, confused ideas of disease, and the careless 
use of medical terms, are necessarily followed by harmful conse- 
quences. For they always reflect the treatment that will be 
adopted. If I were to teach you that inflammation, induration 
and ulceration are essentially one and the same disorder, my indi- 
vidual error as a teacher would react against the welfare of your 
patients and of the community, through you, because it would set 
you upon the wrong track in therapeutics. 

Remember, therefore, that the discharge from the uterine cervix 
of such products as I have described does not 

Ulceration is incidental. . 

imply that there is necessarily any ulceration 
thereof. Take a pair of speculum forceps, such as I hold in my hand, 



460 . THE DISEASES OF WOMEN. 

■wrap a bit of cotton about them in this manner, and pass them 

through the speculum as far as the os uteii. Let them approach 

the cervix very cautiously. Then turn them over and over, thus, 

very gently, and you will wind up and remove 

A practical hint. ,. . . n . 

the stringy mucus just as if it were a spider s 
web. If this little manipulation is carefully performed, the free 
surface of the mucous membrane will be left exposed, and you 
will see at a glance whether you have a case of simple inflamma- 
tion or of ulceration to deal with. But if you undertake to remove 
the mucus from the diseased part without this precaution, and mop 
it away roughly, the delicate vascular surface, more especially the 
hypertrophied villi will be wounded, and the part so bathed in 
blood that you can get no very definite idea of the lesion. For 
the same reason it is best to be careful in the introduction of the 
speculum, more especially the quadri-valve and cylindrical varie- 
ties, lest you injure the cervix and fail in your object. 

Now a simple abrasion of the os-uteri may be, and most fre- 
quently is, merely incidental to the endo-cervicitis. The leucor- 

rhceal discharge does not come from the denuded 
ceraJd s^face. rom an u ~ surface, but is derived from within the canal of 

the cervix. If, however, the ulceration is deep- 
seated, and granular in character, and especially if the granula- 
tions are exuberant, and the patient is scrofulous, a large quantity 
of pus may be secreted from the surface of the sore. 

You will be able to diagnosticate endo-cervicitis from cervical 
metritis, by the absence of febrile action, and of local tenderness, 

which almost invariably accompany the latter ; 
^Diagnosis from cervical by the existence of a i eu corrhcea, of congestion 

of the mucous membrane about and within the 
cervix, the open state of the os-uteri, the eversion instead of the 
retraction of its lining membrane, and by its relation to the scrof- 
ulous and catarrhal dyscrasise. Although these diseases are some- 
times found to coexist, yet such a complication is not frequent. 

The prognosis should be guarded. If you promise to cure suet 

cases in a given length of time you may be sadly disappointed ; 

' for they are by nature chronic and tedious. And 

Prognosis. . . 

there are so many causes which,, directly and 
indirectly, modify the vascularity of the part that is inflamed, and 
derange and damage its glandular function, that your best inten- 



CERVICAL ENDOMETRITIS, ETC. 461 

tions will be thwarted and your best prescriptions often rendered 
of no effect. Sometimes the sexual instinct and appetite of his 
patient is a sworn enemy of the physician, that overrules and 
overcomes his determination to cure her of this disease. Whether 
spontaneously aroused, or purposely stimulated, or whether it be 
gratified or repressed, the effect is to antidote and to counteract 
his efforts, to complicate the case, and to postpone the cure. 

The return of the monthly crisis multiplies the contingencies 
with which this disease is beset. So also the central and depend- 
ent position of the womb, and more especially of its neck, and its 
relation to other organs, both near and remote, all of which tend 
not only to render the attack persistent and almost perpetual, but 
to bring on relapses when it has apparently been cured. 

Treatment. — Nothing is more common than for young physi- 
cians to claim that a few doses of this or that remedy have sufficed 
to cure a case of cervical leucorrhoea. And this 

Of speedy cures. 1 . 1 

independently of sexual excitement, the monthly 
exacerbation, and all the drawbacks which are but so many obsta- 
cles in the way of their superiors in age and experience. The 
fact is, their remedies may have been properly chosen, and most 
appropriate to the case in hand, but in the nature of things it is 
ascribing too much to them to insist that they are competent to 
cure such cases so promptly and decidedly. Merely to change 
the character or the quantity of the flow, or altogether to arrest 
it, is not to perform a radical cure. For relapses are the rule and 
not the exception. The doctor may plume himself on his skill in 
its treatment, and declare his patient well again, but the next day, 
the next week, or the next month, some exciting cause which is 
contingent upon her organization, or her position in the family, or 
in society, may upset all that he supposed he had accomplished, 
and consequently she is "as bad as ever again." 

Most of the exciting causes of enclo-cervicitis are avoidable. 
It will be necessary to remove your patient from under their influ- 
ence. You will see to it that there shall be no 

Remove the cause. 

sudden interruption or derangement of men- 
struation ; that her clothing is suitable and sufficient ; that her feet 
are warmJy clad and dry ; that her skirts are suspended from the 
shoulders ; that there are no ligatures about her body or her limbs , 
that she is not the victim of excessive sexual indulgence (espe- 



462 THE DISEASES OF WOMEN. 

cially at or near the month), of uterine displacements, constipa- 
tion, dysmenorrhea, dysuria, ovaritis, blennorrhagia, rough riding, 
wearisome exercise, or the wearing of an abominable (not abdomi- 
nal) supporter or pessary. 

Both with reference to the prophylaxis and the cure of this 
complaint, an inherent tendency to scrofulous and catarrhal in- 
flammation should receive your early and con- 

The need of nourishment. , J 

stant attention. If your experience shall cor- 
respond with my own, you will find that the prime indication 
with this class of subjects is to have them sufficiently nourished, 
to bring their assimilative functions and their blood up to the 
healthy standard. In other words, you must not only stop the 
drain, whatever it may be, which is exhausting their vitality, but 
also supply them with such available nutriment as shall more 
than compensate the waste that has been going on. It may be 
quite as difficult to select the proper diet, and to arrange all its 
details to suit each individual case, as it is to select the remedy, 
but, in my judgment, it is quite as requisite to the cure of the 
disorder. 

Milk in some form, bread and milk, cream, beef, mutton, oys- 
ters, fish, fowl, game, soups and broths of different kinds, if not 
too greasy, the whites of eggs, and malt liquors, 
may supply this need. Cod liver oil has bene- 
fited some of these cases amazingly. In others the digestion has 
been improved and the general strength fortified by the use of the 
acid phosphates. Brandy and whisky are usually interdicted, 
but sometimes a mild native wine, or the extract of malt, may be 
allowed. Condiments and coffee are often injurious, while acid 
drinks are not only grateful but useful also. 

Some of these patients will never get well while they remain 
within doors. Others need a change of scenery and surround- 
ings, and they must travel. And yet another 

Travel and exercise. . 

class must be kept in a passive state. But how 
to fill these indications without harmful consequences is the ques- 
tion for you to decide. When you have regulated all these inci- 
dental matters, which I assure you are much less trivial in their 
bearings than they seem in their recital, the case will be more 
than " half cured," and you will be prepared to study its special 
therapeutics. 



CERVICAL ENDOMETRITIS, ETC. 463 

Excepting for the purpose of cleanliness, vaginal injections are 

of little avail in this disorder. For unless the mucous membrane 

that covers the vaginal portion of the cervix is 

Vaginal injections. . -i-ii i 

also inflamed, or ulcerated, they do not reach 
the diseased part. And yet you will find that a majority of those 
who have already been under treatment for this disease have been 
in the habit of taking medicated injections of various kinds. 
With a view to clear the vagina of the unnatural discharges 
which come from the neck of the womb, to prevent their decom- 
position, and also, in case the endo-cervicitis is specific, to pre- 
vent the inoculation of the adjacent parts with the poisonous 
flow, we may prescribe injections of Castile suds, or of glycerine 
and tepid water. 

A better means of relief, however, consists in the direct appli- 
cation of pure glycerine to the inflamed cervix. This substance 

has the power of causing a free discharge of 
ceHne topical use ° f gly ~ serum from its engorged capillaries, and thus of 

removing an incidental cause which not unfre- 
quently serves of itself to perpetuate the disease. The determi- 
nation of blood to the dependent cervix, and its stasis therein, is 
a prime cause of the excessive and abnormal secretion from the 
cervical glands. If we relieve this local embarrassment of the 
circulation, it is like extracting a splinter from the flesh in a case of 
irritative fever. Moreover, the expedient is simple, available and 
harmless. It neither interferes with the use of internal remedies 
nor antidotes them. It has no injurious effect upon menstruation, 
nor does it entail any reflex or remote consequences upon other 
organs, which may or may not be implicated. During the past 
six weeks this patient has had no other treatment. We have not 
given her a grain or a drop of medicine, and yet she is almost 
well. 

A good method of applying the glycerine is to make a firm 
tampon of cotton, tie a thread about the middle of it to facilitate 

its removal, saturate it thoroughly with pure 

How to apply it. , . . 7 • j? 

glycerine, and introduce it into the vagina alter 
the patient has retired for the night. It should be pushed up 
against the cervix and left there until morning, when it can be 
withdrawn. The removal of this tampon will be followed by a 
more or less copious discharge of a thin serum, which is the pro- 



464 THE DISEASES OF WOMEN. 

duct of the " insalivation," as it has been termed. This little 
operation may be repeated, according to circumstances, from one 
to three times each week during the inter-menstrual period. 

Another, and a more direct means of applying this substance is 

to take such an instrument as this, which is a flat uterine probe, 

armed with a bit of cotton-wool or soft sponge, 

Another method. . . . . . 

saturate it with the glycerine, introduce it into 
the cavity of the cervix and pass it as far as the internal os uterL 
Turn it about gently, and after . a few seconds it may be with- 
drawn, freshly charged with glycerine, and again introduced. 
Fortunately the open state of the external os, in almost all of 
these cases, facilitates and even suggests a resort to this topical 
means of relief. The patient should remain for a time upon her 
couch, and should not go to ride or to walk for several hours after 
the application. In very rare cases the glycerine is poisonous to 
the mucous membrane, and can not be used in the manner direct- 
ed. You should always be careful to select the best quality of 
glycerine for internal use. 

If the discharge is either purulent or puriform, the tincture of 
calendula may be added to the glycerine, in the proportion of one 

drachm to two ounces each of glycerine and 

Calendula, hydrastis, etc. -,...,,'■, 1 -i • -i i -n r\ i 

distilled water, and applied locally. Or the 
hydrastis, hamamelis, arnica, or baptisia, may be used in the same 
way. In exceptional cases, occurring in strumous subjects, and 
which are very chronic and intractable, one drachm of the tinct- 
ure of iodine may be mixed with two ounces of glycerine, and 
applied with a camel's hair pencil to the canal of the cervix. I 
have sometimes used the oleaginous collodion with the best pos- 
sible results. 

Although, as I have already said, in endo-cervicitis the inter- 
nal os uteri is in most instances closed, yet because it might pos- 
sibly be agape, or readily forced open, it is not 

Intra-cervical injections. ... , . ■■ 

safe to resort to injections thrown into the cer- 
vix, lest the fluid pass into the womb, and even into the abdo- 
minal cavity. 

No matter what the variety or the degree of the uterine dis- 
placement in this disease, every species of me- 

Pessaries. . i-i -i t l j_i 

chanical support is more likely to do harm than 
good. The only pessary that I ever employ in these cases is the 



CERVICAL ENDOMETRITIS, ETC. 465 

saturated tampon, of which I have just spoken, which some of my 
patients wear whenever they are upon their feet. Exceptionally 
the perineal strap or pad is palliative, and will permit of moder- 
ate locomotion and of riding out into the fresh air. But the or- 
dinary supports, and especially the stem-pessaries, are absolutely 
harmful in the treatment of those uterine deviations which are in- 
cident to this form of endometritis. 

In very tedious cases compression of the inflamed mucous 
membrane exerts a salutary influence, not only in lessening the 
copiousness of the flow, but in curing t4ie 
lesion upon which it depends. For this pur- 
pose the carbolized sponge tent may be introduced from time to 
time, and left in situ for some hours. Or the other varieties of 
tent may be preferred. Simpson's ebony bougies sometimes answer 
equally well. Medicated bougies and suppositories are not of any 
especial value in endo-cervicitis. Compression would, however, 
be harmful, excepting in chronic cases of this disease, and should 
always be used with caution. 

Concerning the employment of caustics in the management of 

this disease, they certainly are no better indicated than they 

would be in nasal catarrh, influenza, catarrhal 

Escharotics. i i -i • • i^t 

ophthalmia, or a " cold m the head. It would 
be just as reasonable, and equally efficacious, to apply the nitrate 
of silver, or chromic acid indiscriminately, in the one case as in 
the other. Physicians succeed in curing bronchial, renal and in- 
testinal catarrh without the topical use of alum, the acetate of 
lead, or even of carbolic acid, and why should they claim that 
a similar inflammation of the mucous membrane within the uter- 
ine cervix is not, and can not also be responsive to milder 
means of cure ? Theoretically, the adherents of the Bennet 
school are certainly wrong in their deductions ; practically, I 
believe, they are working more mischief (unwittingly, to be sure) 
than any equal number of physicians, of whatever denomination, 
the world over. For what excuse can there be for converting a 
case of simple endo-cervicitis into one of open ulceration of the 
os uteri, in order to cure it ? And how shall the intelligent phy- 
siologist excuse himself to his own conscience for sealing a dis- 
charge from the neck of the womb, regardless of the consequences 
that may be entailed upon his patient ? 
so 



466 THE DISEASES OF WOMEN. 

I have long been of the opinion that, in the selection of the 

constitutional remedies for this form of leucorrhoea especially, the 

physical characters of the flow, as it is ordi- 

A fallacious practice. , . . 

narily obtained, nave been considered more im- 
portant and suggestive than the facts of the case will warrant. 
The usual mode of noting the peculiarities of the discharge which 
comes from the cervical canal is fallacious. An albuminous secre- 
tion, which is alkaline in its reaction, is subject to contact, suc- 
cussion, retention and admixture with an acid mucus in the vagina, 
which changes its properties in many respects, if it does not alter 
it entirely, after which the product is recommended to be taken 
as a criterion of the actual lesion, and a guide in the choice of the 
remedy. Under these circumstances, nothing is more natural than 
that the flow should become white, watery, milky, opaque, cheesy, 
curdy , yellowish, brownish, flesh-colored, or even greenish. And, 
since the conditions which give rise to the varying qualities of the 
ieucorrhceal flow (in endo-cervicitis, or uterine catarrh), are purely 
accidental, and contingent upon the passage of that flow through 
the vagina, I feel like insisting that they are not to be depended 
upon as therapeutical data. 

Take a parallel case. Suppose that, in nasal catarrh, the dis- 
charge were first subjected to the action of the vaginal mucus, or 
to any other acid mixture, and afterwards submitted to you as 
representing the proper pathological product itself, what kind 
of an Idea would you form of the disease in question ? And sup- 
pose, farther, that a physician should insist that, after such manip- 
ulation, the color and other characters of the discharge would 
indicate the remedy, what would you think of him ? 

Now, I propose, that in order to obtain a correct idea of the 
secretion which is poured out by the cervical glands in uterine 

leucorrhoea, we should not trust to the patient's 

Rule for examination of • ■ _c j i j.j *j_i 1 

the flow in cervical leu- version oi the matter, neither to our own exam- 
ination of the flow, when it has been mingled 
with the vaginal mucus, but that, in order to examine it properly, 
we should take the discharge directly from the cervix uteri itself, 
as well for curative as for diagnostic reasons. Then, as in nasal 
catarrh, we would have the original product unchanged, and what- 
ever we could learn from it that would help us to differentiate be- 
tween remedies would be much more satisfactory and trustworthy 



CEKVICAL ENDOMETRITIS, ETC. 467 

in every respect. And I do not know why a leucorrhceal secretion 
should not be thus carefully inspected from time to time, as we 
examine the sputa in pneumonia, or the urine in a case of Bright's 
disease. Moreover, it should be done in the same manner in mak- 
ing our provings. 

I apprehend that the varying qualities of a natural secretion, 
as, for example, the menstrual blood, the urine, or the perspira- 
tion, as these fluids are influenced by disease, 
abnormal dLXrS and afford a much better criterion of the structural 
and functional conditions of the organ or organs 
involved, than do the physical properties of products which, like 
the sputa, diarrhceic discharges, and the cervico-leucorrhceal flow, 
are in themselves morbid. If this is true, they also supply us with 
a better guide in the selection of our remedies. 

The physical properties of the flow in cervical leucorrhcea are 
many of them too fickle and varying to be possessed of the prac- 
tical significance which has been ascribed to them. The leucor- 
rhcea itself is but a symptom, and to divide and subdivide it, is 
perplexing to one's patience, and sometimes too transcendental to 
be of real use. If cures have been effected (and they undoubt- 
edly have), when remedies for cervical leucorrhcea have been pre- 
scribed on these shadowy indications, the result must be attributed 
to the fact that they were accidentally suited to the relief of the 
more cardinal and essential conditions underlying those symptoms. 
We may, therefore, depend upon them only when we can not do 
better. 

In vaginal leucorrhcea, however, the thickness, thinness, tenuity, 
color and peculiar character of the discharge, are more distinctive 
and significant. If it has acrid or corrosive properties, we should 
give this clinical fact its proper interpretation. For, excepting in 
case of malignant disease of the womb, as in medullary cancer, 
cauliflower excrescence, and the like, this kind of flow never 
comes from the cervix uteri. Where both these varieties of leu- 
corrhcea co-exist, as they sometimes do, you will generally succeed 
in curing the vaginal form first, and that which depends upon 
enclo-cervicitis afterwards. 

If you can trace the origin of an attack of cervical endo-metri- 
tis to " taking cold," or to an epidemic influenza, no matter what 
length of time has elapsed since the disease set in, you will do well 



468 THE DISEASES OF WOMEN. 

to prescribe the remedy or remedies that would have been suited 
to the primary disorder. Whatever remedy 

Practical hints. i- J J 

would have cured the "cold," the influenza, or 
the catarrhal fever, upon which the endo-cervicitis is secondary, 
may suffice to cure its remote effects and to help your patient out 
of her difficulty. 

Due notice must also be taken of the catarrhal dyscrasia, as it 
might be termed, and of the scrofulous and the syphilitic dia- 
theses. So, likewise, of a predisposition to biliary derangements, 
whether it be chargeable to inherent peculiarities, or to the acci- 
dental circumstances of climate, season, an improper diet, or mal- 
medication. In this climate the consideration and study of these 
utero-hepatic complications are indispensable. But above all, you 
will look for the most prominent and trustworthy indications for 
your remedies in those symptoms which are connected with and 
depend upon certain coincident derangements of ovulation, men- 
struation, and of the digestive, the respiratory, the circulatory and 
the nervous systems, and also of the bladder and the rectum. If 
you will adhere closely to this method of selecting the remedy in 
this class of cases, it will enable you to distinguish the true symp- 
toms from these which are only incidental, and perhaps fallacious. 

Thus, if the prominent symptoms complained of are referable 

to ovarian irritation, inflammation, or derangement, they might 

indicate belladonna, atropine, apis mel., colo- 

For reflex ovarian disease. . . . 

cynth, phosphorus, alumina, platina, enma, 
hamamelis, pulsatilla, zincum val., lachesis, caulophyllin, lilium 
tig., conium, podophyllin, bufo, or some kindred remedy. 

Or, if some menstrual embarrassment or difficulty gives a par- 
ticular stamj), or character, to the symptoms, it may be indispens- 
able for you to study the pathogenesis, and the 
f F mens°truatfon. t dlsor ers published experience of the profession with 
bovista, secale cor., sabina, alumina, ferrum 
acet., calcarea carb., lilium tig., baryta carb., sepia, pulsatilla, am- 
monium carb., phosphoric acid, senecin, cocculus, helonin, can- 
tharis, or xanthoxylum. 

For the digestive complieations the more 

For utero- dierestive com- -i • • -\ ••i-i 

plications. common remedies are nux vomica, cham omnia, 

arsenicum alb., mercurius, graphites, lycopod- 

ium, colocynth, veratrum alb., aloes, opium, sepia, carbo veg., 



CERVICAL ENDOMETRITIS, ETC. 4(39 

t3ollinsoiiia can., china, sulphur, hydrastis can., the citrate of iron 
and strychnia, kreasotum, plumbum, pulsatilla, alumina, natrum 
mur., podophyllin, aesculus hip., nitric acid, and mix moschata. 
For those which implicate respiration: phosphorus, bryonia, 
sanguinaria, calcarea phos., calcarea carb., sili- 
spkawrTa^mcnt?. 1 and re " cea, lycopodium, stannum, tartar emetic, lache- 
sis, hyoscyamus, drosera or dulcamara. 
For symptoms connected with the local and general circulation: 
veratrum vir., bryonia alb., stannum, apis mel., 
of\ n he C dTc C ufa e don dls ° rders digitalis, cactus grand., aconite, gelseminum, 
veratrum alb., naja trip., or belladonna. 
For the nervous symptoms, especially in those who are liable to 
Hysteria, almost any remedy in the Materia Medica might be re- 
quired. Most likely, however, you will find 
ne^ous te c r o mp^ca[ion 1 s and what you want under the head of hyoscyamus, 
ignatia, coffea, moschus, caulophyllin, lilium 
tig., belladonna, atropine, cocculus, gelseminum, cimicifuga, caus- 
ticum, chamomilla, agaricus muse, sulphuric ether, senecio, taran- 
tula(?), Scutellaria, or cypripedium. 

If the vesical symptoms are the more painful and prominent, 
you should consult the class of remedies most frequently and com- 
monly employed in the treatment of diseases 
' of the bladder and urethra. This class includes 
cantharis, cannabis sat., dulcamara, belladonna, apis mellifica, mer- 
curius, lryoscyamus, camphora, ferrum, chimaphila umb., and the 
•eupatoreum purpureum. 

When the rectal troubles predominate, we have aloes, podo- 
phyllin, mix vomica, sulphur, hamamelis, col- 
tom°s! euter °- recta symp " linsonia can., and the sesculus hippocasta- 
num. 
Do not understand me as recommending that these remedies 
shall be given consecutively, or without discrimination. In classi- 
fying them my object has not been to supersede 
the necessity for their differential study and 
adaptation, but to indicate the variety of s}miptoms which, in the 
treatment of this vexatious disorder, do really afford the most 
trustworthy guides in the selection of our means of cure. For 
almost every one of them has some especial relation to diseases 
of the uterine cervix. 



470 THE DISEASES OF WOMEN. 



CERVICAL ENDO-METRITIS. 



Case. — This woman is 30 years of age, she had one child which 
is now eight years old, and has had no miscarriage during that 
time. The ninth day after her confinement she got up, but was 
obliged to again take her bed, because of prolapsus of the womb. 
Previous to the birth of her child she had some spinal trouble, which 
was much aggravated after confinement, and her physicians diagnosed 
an abscess on the back over the right hip — for which the hot iron 
was used and this was kept open for one year, for three years fol- 
lowing she was confined to her bed. She now complains of con- 
stant back-ache, and bearing down pain for a week previous to the 
flow, which is irregular, but scanty, lasting but one or at most, 
two days, and is followed by sick-headache. The left leg gets 
numb if she lies on that side, and is worse in damp weather. On 
local examination, we find the uterus prolapsed, lying but one 
inch within the vulva, also a partial laceration of the perineum, 
the os is large, patulous, and is button-hole shaped, The cervix 
is swollen, red, and very tender, she has no leucorrhcea. The 
sound passes without obstruction, and there is no subinvolution. 
Tartar emetic 3, three times a day. 

The points in this case are the non-increase in the depth of the 
womb ; the scanty menstruation ; the enlargement of the body of 
the cervix as a complication ; the expulsive uterine pains in advance 
of the flow ; the prolapsus uteri ; and the numbness of the left leg. 
Each and all of these symptoms are referable to the hyperplasia of 
the neck of the womb and to the rent in the perineum. If the 
laceration ol the cervix played an important part in this case there 
must have been subinvolution with chronic metritis, and possibly 
cellulitis, and menorrhagia. 



ART OIXTH. 



THE DISEASES OF LACTATION. 



LECTURE XXIX. 

ABSCESS OF THE MAMMARY GLAND. 

Burrowing- abscess of the mammary gland with a sinus— on weaning a child, and the 
subsequent treatment of the mammary glands— Galactorrhcea— Excoriated nipples. 

Although the diseases of lactation belong more properly to the 
Puerperal department of the Hospital, in which I shall speak of 
them at the bed-side, there are some of the more common of these 
affections that will come into our general clinic. Prominent 
among them are such as are due to over lactation, non-lactation, 
lactation which is co-incident with menstruation, sub-acute and 
chronic abscess of the mammary gland, and excoriated nipples. 
It happens that we can show you a number, of such cases this 
morning. The first on the list is one of burrowing abscess of the 
mammary gland with a sinus. This is a very unfortunate condi- 
tio;., and one that will draw upon your patience in a peculiar 
manner. You will, therefore, observe its symptoms carefully. 

Case. — Mrs. -, aged 28, has two children, the youngest of 

which is three months old. She complains of a " gathered breast," 
which began to trouble her seven weeks ago, or when the babe 
was five weeks old. She first noticed what appeared to be a small 
"cat-boil" on the right breast, which was not very painful and 
did not in the least interfere with nursing. It, however, contin- 
ued gradually to increase in size, and to become more tender. 
Three weeks ago her physician advised that it should be poulticed 
and afterwards freely lanced. The former part of the prescrip- 
tion was tried, but she would not consent to its being opened. As a 
consequence, the abscess broke at the end of another week, and 
although it seemed but a small affair, discharged a large quantity 
of healthy pus. The orifice through which this fluid escaped has 



472 THE DISEASES OF WOMEN. 

continued to enlarge until it is now about the size of the nail of 
my index ringer, and, only yesterday, she was startled by discov- 
ering that whenever the child nurses, or she swallows anything, 
and sometimes when she moves the right arm, the milk escapes 
quite freely from it. Two days since, another " boil " made its 
appearance at the lower and outer margin of the same breast, and 
now, you see the hardened, smooth, glossy and convex outline of 
the surface at that point, as the redness, and also the pain of 
which she complains, indicate that the suppurative process is still 
going on. She is weak and feeble, with slight hectic, unrest, 
anorexia, and is withal very much discouraged. 

Unless it be located in the loose cellular tissue about the nipple, 
the mammary abscess which points like a boil is apt to be a serious 
and deep-seated one. This is especially true if the local and con- 
stitutional symptoms indicate that the gland has been inflamed for 
a considerable time. Under these circumstances, pus may form 
and collect at the base of the breast, or in the areolar structure 
that separates the lobules, long before there is any external sign 
preparatory to its escape. The size of the abscess proper is, there- 
fore, no criterion of its extent or gravity. Boils situated about 
the margin of the breast, and especially at its lower border, not 
unfrequently give vent to the contents of a burrowing abscess 
which may have existed for some weeks, and committed great 
havoc with the gland itself. There may be only one of these, but 
usually there are two or more which ripen successively. 

We occasionally meet with superficial abscesses that only involve 
the integument covering the gland, but these are not necessarily, 
or indeed frequently, seen in nursing women. They occur in young 
girls, in consequence of tight lacing, the wearing of hard and un- 
yielding pads over the breasts, or of bruising those organs in some 
accidental way, and scarcely deserve the name of abscess. 

The form of milk abscesses of which this is an excellent illus- 
tration, is peculiar to depraved conditions of system which consti- 
tute a species of cachexia. They are very prone to become sinu- 
ous, and the canals which are formed may be either superficial or 
deep-seated, running through or beneath the gland in every direc- 
tion. Multiple abscesses may communicate in this manner. 
Unless relieved by proper means, these sinuses may even become 
fistulous. It has happened that the entire mammary gland has 
been destroyed and discharged through these openings. 



ABSCESS OF THE MAMMARY GLAND. 473 

In the case under review, the extravasation and escape of milk 
is caused by a rupture of one or more of the proper lactiferous 
ducts, whieh are compressed during suckling, deglutition, and also 
when the arm is moved. It is hardly necessary to remind you that 
these symptoms require immediate relief, else they may persist 
and increase in severity until they destroy the patient's life. 

Treatment. — I have more confidence in phosphorus and silicea 
than in any other remedies for sinuous and fistulous abscesses of 
the mammary gland. It is best to give them separately. Perhaps 
you will succeed more frequently with the former than with the 
latter. They should be given in the sixth, or a higher potency, 
and the dose repeated every three to six hours. It has been claimed 
that the local application of the tincture of phoshorus in tepid or 
<jool water is very serviceable also. The phosphorated oil of the 
shops will sometimes answer an excellent purpose as an external 
application. 

My practice has been, in most cases of this kind, to resort to the 
topical use of granulated sugar, which is a simple and unobjection- 
able domestic remedy. Applied directly to the 

A domestic expedient. 

surface of the ulcer at the mouth of the sinus, 
whence the pus or milk, or both these escape, it stimulates fresh, 
healthy granulations, and closes the unnatural outlet. It oper- 
ates kindly and speedily, is a good antiseptic, and is always avail- 
able. It may be insinuated into the canal without doing any pos- 
sible harm, or causing severe pain. 

If this simple expedient fails, you may inject a weak solution 
of tincture of calendula into the sinus by means of a clean ureth- 
ral syringe. And the same solution may also be applied over the 
ulcer at the site of the abscess. Calendula is sometimes wonder- 
fully efficacious where there is considerable loss of the integu- 
ment, and where an extravagant quantity of pus is formed. 

The old plan of slitting up these sinuses with a knife was cruel, 

barbarous and unnecessary. It is undoubtedly true that, in a 

majority of cases, these deep-seated abscesses 

The knife. J J ' r 

once formed would seldom become sinuous and 
fistulous if they were promptly and properly opened, but this fault 
does not justify the subsequent slashing and hacking of these 
delicate organs. There is a proper time for all things, including 
the lancet. And the same is true of the caustic and astringent 



474 1HE DISEASES OF WOMEN. 

injections which have been thrown into these passages hereto- 
fore. 

As in other abscesses that involve a considerable drain upon the 
patient's strength, we must counteract the loss and fortify against 
it. This woman should have a good, nourish- 
ing diet of eggs and lean meat. Beef is prefer- 
able, and may generally be taken in the solid form. Of all vege- 
table substances which are appropriate to cases of this kind, oat- 
meal is best. Bread made from unbolted wheat flour — thus 
securing the phosphorus which is contained in the hull of the 
grain, — is also advisable. According to Agassiz's theory con- 
cerning the large relative proportion of the same element in fish, 
we may sometimes select from this class of food. The fish should 
also be lean. Fresh air and sunlight, with freedom of the mind 
from all harrassing cares, are excellent and available tonics. 

Mrs. will take of phosphorus 6th, a dose every four hours 

during the day. The granulated sugar to be applied twice daily, 
The diet to consist of brown bread and butter, and rare roast 
beef, with dry, mealy potatoes. She must nurse her babe from 
the left breast exclusively. The right one should, however, be- 
well drawn by means of a breast-pump each morning and even- 
ing, and then kept soft and warm. Let her report at the end of & 
week. 

ON WEANING A CHILD, AND THE SUBSEQUENT TREATMENT OF THE 
MAMMARY GLANDS — GALACTORRHEA. 

Case. — Mrs. Z , aged 30, applies for advice concerning the 

propriety of weaning her child, and likewise for instructions rela- 
tive to the best method of procedure if this expedient is deemed 
proper. The baby is eleven months old, and healthy in every 
respect, not having had a day's sickness from its birth. The 
mother's health is also excellent. The milk is furnished in good 
amount and quality, and although she really dreads to wean the 
little one, she will nevertheless do so if it is thought best. By 
the advice of her former physician she nursed an elder child, now 
four years of age, until it was eighteen months old. Her infant 
feeds well, and, if it were allowed, would eat almost anything. 
It has a mouthful of teeth. She fears that when she takes it from 
the breast altogether, she may have trouble with the glands them- 



ABSCESS OF THE MAMMARY GLAND. 475 

selves. For she is somewhat peculiar in this respect, that with 
her the milk continues to be secreted for a long time after it has 
ceased to be regularly drawn off. Thus when she weaned her 
little girl, two years and a half ago, the milk " continued to come 
into the breast," as she says, for four or five months longer, her 
menstruation being quite regular meanwhile. And following an 
abortion, that she once experienced at the fourth month, she had 
a considerable flow of milk for the space of nearly six months. 
For this reason she feels exceedingly anxious to know what course 
is the proper one. 

In the practice of your profession you will be frequently con- 
sulted in cases similar to this. You will observe that some mothers 
apply for professional sanction to wean their 

Fashionable pretexts for i • -i i , i , r> , i 

the indiscriminate weaning children early, and, indeed, that many of them 

of infants. . -.. 

prefer not to nurse their babies at all. lnese 
most unnatural and baneful practices are, unfortunately, becom- 
ing more frequent. In all our cities and towns — and in these 
days of railways and telegraphs there are no more country villages 
— the custom of rearing children at second-hand, or by proxy, is 
becoming more and more popular and prevalent. The most silly- 
pretexts are preferred by people in fashionable life for denying the 
little infant the mother's breast. One such mother will decline to 
ruin her bodily form and figure by nursing her own child, another 
considers it vulgar, a third is too much of an invalid herself, while 
a fourth is unwilling to sacrifice the pleasures of the table, of the 
toilet, or of gay and fashionable society, of late hours, or of some 
favorite form of dissipation, for the cares and crosses of maternity. 
Among women of the great middle class of society there is a grow- 
ing aversion to what is both natural and necessary for the welfare 
of their delicate offspring. For the most trivial, and even shame- 
ful reasons, too many little innocents are thus denied their most 
appropriate aliment. The consequence is that a large share of 
American mothers never experience those reflex influences that 
would tend to soften and sweeten their own natures ; and that 
thousands of children are poisoned by all sorts of artificial substi- 
tutes for healthy human milk. 

Another class of mothers place a premium on the luxury of nurs- 
ing their own children. They are never quite ready and willing 
to wean them. If your future observation accords with my own, 
you will have reason to conclude that, with many members of this 



476 THE DISEASES OF WOMEN. 

class, the pleasure derived from the performance of this very natu- 
ral function constitutes the chief enjoyment of their married life. 

Not unfrequently, however, there is another reason for the re- 
solve on the part of these women to prolong the period of lactation. 
As a rule, menstruation is suspended until the 
iact 1 It e ion Ctsoftooprolonsedcnud is ta ken from the breast. This they all 
know as well as we do. They are also aware 
that, while the nursing woman does not menstruate, she is not 
very likely to conceive again. Hence many mothers voluntarily 
continue to suckle their children beyond the proper time, in the 
hope that they may thus avoid too rapid an increase in the family. 
But since there are many exceptions to the rule that a nursing 
woman may not become pregnant, and more especially because the 
health of the child, and of the mother also, may be injured thereby, 
it will become your manifest duty, in some cases, to insist that 
this practice shall be relinquished. 

As a rule, if both the patient and her child are well, the little 
one should not be weaned before it is about a year old. After this 
period the mother's milk becomes deficient in 
iZ he pr ° per dme f ° r wear '~ casem > — a physiological reason why lactation 
should not be prolonged. In deciding upon the 
most proper time for taking the children from the breast, something 
depends upon circumstances. If, for example, the little thing has 
cut its teeth freely and early, and manifests a disposition for a 
mixed diet, being ready and eager to eat almost anything that is 
offered, there will be little risk in weaning it. It will, however, 
be more safe for the child to cease nursing in cool or cold weather, 
as in the fall or winter, than in the late spring or early summer 
months. If a severe epidemic, more especially any alimentary 
disorder, such as cholera infantum or dysentery, is prevalent 
among young children, you should counsel the mother to wait 
until the epidemic has subsided before she puts her child away. 
The almost utter impossibility, in our larger cities, at certain sea- 
sons, of procuring good, healthy cow's milk for the infant, may 
afford another valid reason for prolonging lactation even beyond 
the twelfth month. Statistics prove that after the ninth month, 
weaning is more apt to be followed by mammary abscess than at 
any period between the second and ninth months. 

In the case in which we have just been consulted, the child's age 



ABSCESS OF THE MAMMARY GLAND. 477 

is favorable, it has its complement of teeth, eats well, and is 
thrifty in every regard ; the season (November) is propitious ; 
and there is no disease which at this time is especially prevalent 
among infants and young children. We therefore advise that 
this woman's babe be weaned. 

Treatment. — And now the question is fairly before us ; what 
course is most proper for the mother ? In her case there is a man- 
ifest predisposition to a profuse and prolonged secretion of milk. 
Ordinarily the quantity of milk secreted is in proportion to the 
frequency with which the breast is drawn, or emptied ; the more 
it is nursed, the greater the yield. But in this case a profuse flow 
is furnished by the gland, although none of the product is forci- 
bly withdrawn. Here there is a danger lest the milk may accu- 
mulate and give rise to inflammation, and, ultimately, to mammary 
abscess. Hence we must, if possible, institute measures that will 
avert such a calamity. For it is a species of martyrdom for any 
woman to suffer from an abscess or abscesses of the mammary gland, 
and we should use our best endeavors to spare her such an infliction. 

Where, as in this instance, the flow of milk is very profuse, 

and especially if the child is several months old, I think the wiser 

course is to wean it gradually — say to nurse 

Prophylactic treatment. , , 

it only at night for a time, and to feed it dur- 
ing the day. This plan will prevent the accumulation of a very 
large quantity of milk in the breasts, and also allow the general 
organism to accommodate itself to the new condition of things, 
points which are in some cases most significant. If the mother 
stops nursing abruptly, there will be greater risk of local trouble, 
and of a general derangement of her health, than if the change is 
less sudden and extreme. 

This rule, which has its exceptions, is also applicable in case it 
becomes necessary to wean the child at a very early age. In gen- 
eral, however, it is thought advisable to put the infant away from 
the breast at once, as less troublesome than gradual weaning. 
Afterward, if the ducts become obstructed, and the glands dis- 
tended, hard and painful, a resort is to be had to some artificial 
means of emptying them, and of averting farther trouble. 

Medicines which are believed to have the power of lessening 

the quantity of milk secreted are termed Anti- 

Antigalactics. , 

galactics. They are used both internally and 
externally. Of those which are adapted to internal use the more 



478 THE DISEASES OF WOMEN. 

prominent are belladonna, bryonia, calcarea carbonica, and phos- 
phorus. Besides these, other remedies are suited to lessen a redun- 
dancy of this flow, when it is attended by peculiar symptoms, all 
of which are lacking in this case. For, Mrs. Z. is not ill at the 
present time, and the most diligent search might fail to disclose a 
single symptom of an abnormal condition. Our treatment must, 
therefore, be prophylactic. It should be designed so to diminish 
the quantity of this secretion as to insure the breasts against local 
disease or injury, and the general system from all contingent dis- 
orders. To fill this indication I have more confidence in the cal- 
carea carbonica than in any other remedy. I prefer it in the 
third decimal trituration. Your future experience may cause you 
to decide in favor of some other form or potency of this remedy. 
This is a matter which cannot be settled for yon in the lecture-room. 
In general, the younger the child the greater the danger of 
mammary abscess from weaning it. There are, however, excep- 
tions to this rule also, in which it is almost or 

The age of the child a .. 

criterion of the danger of quite impossible to take the child from the 

mammary abscess. 

breast at any period without incurring the risk 
of this accident. When a physician tells you that he has always 
been able to avoid such a result in his practice, you may safely 
conclude that he has been unusually fortunate, or that his obser- 
vation has been limited. 

Local adjuvants are not only admissible, but, in certain cases, 
necessary also. Most practitioners prefer camphor for this pur- 
pose. Cloths may be wet ivith the common 

Local applications. . 

tincture and applied directly to the breast. Or 
it may be anointed with a mixture of camphor and sweet oil ^— 
the camphorated oil of the shops. A saturated solution of cam- 
phor in glycerine makes a more pleasant and equally useful prep- 
aration, which may be kept constantly applied over the gland by 
means of flannel compresses. 

Several of my medical friends assure me that they have derived 
the most satisfactory results from the topical employment of cold 
water, as a preventive against mammitis and mammary abscess in 
cases of this kind. I have no experience therewith. They recom- 
mend to apply a wet compress directly over the gland, and to pro- 
tect the clothing by a dry one outside. This is to be renewed 
from time to time, the water being at the temperature of ordinary 



ABSCESS OF THE MAMMARY GLAND. 479 

well or hydrant water. They claim that the faithful use of this 
simple means will spare much subsequent trouble to all concerned. 
Another method consists in covering the breast with one or more 
layers of flannel, and then applying a bladder which is partly 
rilled with broken ice. Persistent rigors and chilliness, however, 
contra-indicate the use of cold applications of all kinds. 

A stimulating lotion may also be made of black pepper QPiper 
nigrum}, by permitting it to stand for a considerable time in good 
hrandy. The pepper should, however, be in the grain and not 
ground, or pulverized, otherwise, by insinuating itself into the del- 
icate skin, especially in the region of the areola, it might occasion 
much suffering. This lotion may be applied in the same manner 
as recommended for the glycerole of camphor. 

In inflammatory cases in which the pain and throbbing of the 
gland are severe, or if the pains are neuralgic, the application of 
the belladonna plaster will sometimes afford the greatest possible 
relief. It may serve not only to abort the suppurative process, 
but also to put a stop to the further secretion of milk. This 
expedient seems especially adapted to those cases in which it is 
advisable, directly after labor, to institute measures for the preven- 
tion of a free flow of the lacteal product. Dr. Marley recommends 
to smear the breast with the extract of belladonna.* He has em- 
ployed this treatment .for the prevention of mammary abscess 
with almost uniform success in 44 cases, in which a prompt arrest 
of the lacteal secretion was necessary. 

When the breasts are large and flabby, the extra weight may be 
relieved by a broad handkerchief, a net-work supporter, or by 
strips of adhesive plaster properly applied. 
i)r^st a s nsofsupP ° rtforthe These plaster-strips are sometimes used to 
secure uniform compression of the glands, and 
thereby diminish their secretion. The bandage of Seutin has been 
•extolled for the same purpose. 

Our patient should abstain from soups and all kinds of liquid 

food, and satisfy her appetite chiefly with solids. It would not 

be best for her to drink largely of any fluid 

The proper diet. J 

whatever, more especially of water or malt 
liquors. She will take a dose of the calcarea carbonica every 
night, and apply the camphorated oil externally. 

* Ti-ansactions of the Obs. Society of London. Vol. I., p. 31. 



480 THE DISEASES OF WOMEN. 



EXCORIATED NIPPLES. 

The next case on the list this morning is one which has come as 
an inheritance from the puerperal state, and which will have its 
counterpart to your experience as general practitioners. It will 
afford you a good illustration of a class of cases which some wise 
physicians and nurses consider to be always preventable, but 
which will happen now and then in spite of the greatest care and 
precaution. It is a case of excoriated nipples, and, when we con- 
sider the delicate organization of the part involved, its peculiar 
function, its liability to traumatic injury, its exposure to the action 
of the mucus from the mouth of the infant, and to the heat and 
suction that are applied, the marvel is that such lesions are not 
more frequent. 

Cases of this kind are sometimes very difficult of cure either 
because the patients general condition favors their becomings 
chronic and intractable, because there is some trouble of the gland 
behind them, and of which they are the outlet, or because of the 
necessity of putting the babe to the breast often enough to empty 
it and nourish the child. 

Case.— Mrs. G.'s third child is but four weeks old. This babe 
is a fat hearty boy, while the mother is slender but of general 
good health. She reports having passed through her lying-in 
without any serious illness. She has, however, suiferecl extremely 
from sore or excoriated nipples. This trouble 'began immediately 
after the appearance of the milk, on the third day after delivery, 
and has continued until the present time. She says that she 
could "get on very well, but that each time after nursing, the 
nipple is left raw and bleeding;" and that " when the little fellow 
lets go his hold, it almost takes her life." She had a similar ex- 
perience with each of her former children, from which, despite all 
the means employed, she did not recover until they were weaned., 
at the agfe of three months. 

This is by no means a trivial case. In private practice you 
may encounter forty of them for every one like that upon which 
my brave colleague, the professor of surgery, has just performed 
a capital operation. And, unless you know how to treat them, 
each one may give you forty times as much trouble. Although 
the nipple may be accidently torn off by the child, you will not 



ABSCESS OF THE MAMMARY GLAND. 481 

he permitted to dispose of this troublesome member by ampu- 
tation. 

Sore nipples are more frequent in primiparse than in multiparas. 

There are those, however, who, like our patient, suffer from them 

with each successive pregnancy. The affection 

^iost frequent in primi- SO metimes begins during the later months of 

gestation, but usually not until the child has 

been " put to the breast" a few times. If the skin covering the 

nipple is very tender, thin and delicate, the first 

Local and general causes. . , . . . 

attempts at nursing may increase its sensitive- 
ness or strip off the epidermis in some places. The more vigorous 
and voracious the child the greater the danger in this respect. In 
women with light complexions, and light or red hair, the cuticle 
is very delicately organized, and easily removed. There is a 
popular idea that, because they are stronger and more rough in 
their little manners, boys are more apt than girls to wound the 
nipple while nursing. There is little doubt but that this painful 
affection is sometimes due to the removal of the sebaceous matter 
from about the nipple by the mouth of the infant. In other cases 
the nipple is bruised by the gums. Or it may arise from a lack 
of cleanliness, or from not drying the nipple so carefully as should 
be done after nursing. Sometimes it may spring from a depraved 
or cachectic condition of the general system, chargeable to 
original organization or to the drainage which is consequent upon 
gestation. Again, it may be caused by an aphthous condition of 
the child's mouth, whereby it has been inoculated with a poison- 
ous principle. In exceptional cases the child may be syphilitic, 
and the erosion of the nipple will be found to present some 
specific peculiarities. 

The first symptom complained of is a burning or scalding of 
the nipple when the child takes hold of it, or upon its removal 
from the breast. This sensation may be accom- 
panied or followed by pain which is more or 
less acute. Sometimes the nipple, and again the whole breast, 
feels as if bruised. Or they may be the seat of acute, lancinating 
or stinging pains. In some instances the mother can scarcely 
persuade herself that her nipple has not really been torn off by 
the child. The torture of nursing the infant is sometimes very 
great. A fissure or chap in the skin, which is scarcely visible to 



482 THE DISEASES OF WOMEN. 

the naked eye, may be sufficient to cause the most extreme and 
exquisite suffering. Women of the utmost courage and fortitude 
are not unfrequently brought to tears by this experience. Occa- 
sionally the weak and irresolute, more especially those who desire 
an excuse for weaning the child, refuse to nurse it after a few 
trials. 

Upon careful examination we may, perhaps, find that a consid- 
erable portion of the nipple has really been denuded of its invest- 
ing cuticle. This excoriation is generally most 

The excoriation. ° 

marked at the tree extremity and apex of the 
organ. It may arise from the warmth and moisture of the child's 
mouth, which seem as it were, to blister it and to separate the 
scarf skin from the delicate derm beneath. These abrasions may 
be either superficial or otherwise, according to the length of time 
that has passed since they commenced, and the lack of cleanliness 
or of proper treatment. They sometimes develop into broad 
ulcers, which are exceedingly vascular and irritable. They are 
slow to heal, because the reparative material thrown out is apt to 
be washed away or removed by the child before it is fully 
organized. 

Not unfrequently the fissures will be found to consist of long, 

narrow, linear ulcers, which are deep-seated and intractable, and 

which bleed easily. These ulcers may dip down 

The ulceration. . .- . 

into the nipple perpendicularly from its summit, 
or they may take a transverse direction, and finally cut off one- 
third, one-half, or the whole of the organ. They are exceedingly 
painful, particularly when exposed to the air, and in case the lips 
of the fissure, or hair-like ulcer, separate from each other. They 
may even become fistulous. The symptoms are aggravated by 
each attempt at nursing. The discharge from the abraded surface, 
or from the fissure, soon dries upon the nipple and forms a scab, 
beneath which pus is sometimes collected in considerable quantity. 
The injury done to the nipple by the nursing process may cause it 
to bleed so freely as to sicken the child and induce vomiting. 

In exceptional cases this affection may begin Avith an herpetic 
eruption about the nipple. The little vesicles are broken, 
and the almost constant irritation of nursing causes them to 
develop into ulcers, which finally coalesce and give rise to symp- 
toms such as I have already detailed. At other times it is the 



ABSCESS OF THE MAMMARY GLAND. 483 

-outgrowth of a species of scorbutic cachexia, and accompanies 
the nursing sore mouth. 

Perhaps the most serious consequence of excoriated nipples is 

the danger of mammary abscess, which may result in any case 

from a lack of determination, or from neglect 

sorlnTppfe? abscess from on tne P art °f tne P at ient an d nurse, to have the 
breasts well and frequently drawn. The milk 
accumulates, the gland becomes painful, indurated and inflamed 
from over-distention of its ducts. The suppurative process is 
soon established, and constitutional and local symptoms of a grave 
character follow. It is in this manner that the worst examples of 
mammitis and mammary abscess may be indirectly referable to an 
erosion or ulceration of the nipple. If the patient is addicted to 
the wearing of tight dresses, this unfortunate result is all the 
more likely to follow. 

Treatment. — As prevention is better than cure, so we may save 

trouble by the use of expedients which are designed to prevent 

the possibility of the nipples becoming sore. 

Prophylactics. - .. _. . . 

lney may be " hardened by applications oi a 
weak lotion of the tincture of arnica, of alcohol and water, of 
brandy and water, of a linen cloth constantly wet with rum, by a 
wash consisting of equal parts of the tincture of myrrh and rose 
water, by bathing them in port wine, in green tea, or in a mixture 
of three parts of green tea with one of brandy. Or you may 
direct the use of a cerate of white wax and butter in' equal pro- 
portions. In the case of primiparse, simple prophylactics of this 
kind are especially serviceable in the later months of pregnancy. 
Care should be taken that the clothing over the breasts is not too 
warm and tightly fitting. It should be light and thin, esx^ecially 
during the last month of gestation. These precautionary meas- 
ures are also suited to those who have suffered from sore nipples 
on previous occasions, and in whom, if possible, it is most desira- 
ble to avert such a calamity in the future. 

Here, as everywhere else in the practice of your profession, you 

will find great need of discrimination. For although these and 

other expedients are useful and harmless, when 

Need of discrimination. .,.,..« 

properly applied, they may work mischief if 
wrongly used. And while too much blame is frequently laid at 
the door of monthly nurses, it is still true that they do a great 



484 THE DISEASES OF WOMEN. 

deal of harm by resorting to traditional specifics of whose real 

properties and powers they are ignorant. An eminent author 

says: "Most nurses, indeed, possess a cata- 

Watch the nurse. . 

logue of nostrums — never-iailmg cures — for 
chapped or ulcerated nipples ; and I think many of the most dis- 
tressing cases of the kind we meet with are occasioned by these 
busy characters taking the management on themselves , and, as is 
usual with the ignorant, relying implicitly on the virtue of their 
favored specific alone, without attending to the necessity either of 
protecting the nipple, or of duly evacuating the breast." 

If there is simple abrasion of the nipple, it may suffice to have 
it carefully cleansed and then dried \ r *<h a tuft of soft linen or 

charpie, as soon as the child is taken from the 

breast. Then apply a cold mucilage of slippery 
elm, or, if there is much heat and burning, small cloths wet in cold 
water. Or the nipple may be dusted with some finely-powdered 
arrow-root, starch, gum arabic, borax, or white sugar. Or the oil 
of sweet almonds, arnica oil, simple cerate, or the spermaceti oint- 
ment, may cure the case by the exclusion of air and moisture. 
If there is aphthous ulceration, borax, hydrastijs, baptisia, or 

one of the mineral acids diluted with cool or 

For aphthous ulceration. ■ n -r 

cold water, may be applied topically. In some 
cases simple rose water answers equally well. 

The nitric, phosphoric, and muriatic acids are also curative in 
case of fissures, chaps and linear ulcers of the nipple. The organ 

should be cleansed and dried after nursing, and 

For the linear ulcers. . . . 

a weak solution 01 one ot these acids in water 
and glycerine applied with a camel's hair pencil. Some physi- 
cians place great confidence in a lotion composed of an alcoholic 
solution of gum benzoin and glycerine in equal parts. A domestic 
expedient of real utility in some cases consists in the application 
of the oil which may be expressed from the yolk of a hard-boiled 
egg. Or a species of flexible varnish may be extemporized by 
rubbing four parts by weight of the yolk of an egg with five parts' 
of glycerine in a mortar, and applying it over the whole nipple. 

Dr. Simpson recommended the topical use of collodion ; but this 
is painful, and seldom answers very well. The mixture of collo- 
dion and castor oil extolled by M. Latour might be less severe and 
more efficacious. Some practitioners prefer the arnicated collo- 



ABSCESS OF THE MAMMARY GLAND. 485 

dion. Others the cerates of graphites, or calendula. A popular 
and efficacious remedy in some cases is the mutton marrow. In 
obstinate, chronic cases, the nitrate of silver in stick or solution 
carefully applied will stimulate granulation and close the ulcer. 
Or you may bring the edges of this linear ulcer together and 
secure them in contact by bits of adhesive plaster properly 
adjusted. For this purpose the flexible plaster which is spread 
upon silk is preferable to the old variety. 

If the child nurses directly from the nipple, or, in other words, 

if a shield is not used, the nipple should always be cleansed after 

either of the above named applications, before 

cleanse the nipple before ft j s a a a in put to the breast. The chief obiec- 

nursing again. o J. o 

tion to cerates and ointments is the difficulty 
of removing them under these circumstances. 

You will find upon the table a dozen kinds of nipple shield. I 
can not recommend any of them as suited to every case. My plan 

is to try one and another, if necessary, until I 

Choice of nipple shield. ,, , . ,—, 

nnd the one that my patient can use. lne more 
simple the instrument the better. If it has too long a teat it will 
be very apt to occasion soreness and inflammation in the roof of 
the child's mouth. It should be kept sweet and clean. In case 
the breast is so exceedingly sensitive that the mother cannot beai 
it touched, the shield which is arranged with a flexible tube 
between the child's mouth and the nipple of the mother answers 

best. If the, milk does not flow very readily 

Precautions. - . .. .. 

through the shield, it may first be drawn a lew 
times by an older child, or very carefully by the nurse. If the 
child refuses to take hold, a little tact and starvation will mend 
his manners. The shield should be used on both breasts, and not 
upon one exclusively, else while one gland is well drawn the other 
may not be half emptied, and mammary abscess may follow* If 
the skin of the nipple is very delicate, the shield should be used 
from the first, and the babe not allowed to take hold of the nipple 
at all. 

The advantages of this little instrument are that while it 
secures, if appropriately and carefully used, a thorough evacua- 
tion of the breast — preventing the inflamma- 

Benefits of the shield. i ' 

tion and suppuration which in many cases would 
be inevitable without it — it also averts and alleviates suffering. 



486 THE DISEASES OF WOMEN. 

By preventing the removal of reparative material which is thrown 
out, as well as by allowing lotions and ointments time to act, and 
by keeping the nipple from direct contact with the child's mouth, 
protecting it from the injurious results of suction and friction, it 
hastens the cure. The child should be nursed regularly, as often 
as once in three hours during the day. 

If there is a high degree of local inflammation, soothing appli- 
cations of cold water or rose water, or, better still, a cold emol- 
lient of slippery elm, may be applied. In some 

For local inflammation. ... ., . , 

cases it is impossible to cure an excoriated or 
ulcerated nipple while the inflammation in the loose cellular tissue 
within and about the base of the organ continues. Weaning is a 
final expedient. 

Among the internal remedies calcarea carbonica, sepia, sulphur, 
graphites, rhus tox., chamomilla, silicea, mercurius, alumina, hepar 

sulphuris, nux vomica and causticum are the 

Internal remedies. . . 

more prominent. In selecting the appropriate 
remedy particular prominence should be given to the patient's- 
antecedents, the peculiar condition of her health during preg- 
nancy, and to acquired predispositions, as well as to the distinctive 
symptoms of which she complains. 

No matter how apparently trivial the case, we should never for- 
get that its neglect may lead to serious conse- 
a practical hint. quences, and chiefly because the patient is still 
in the puerperal state. This fact should have 
its influence in the selection of the constitutional treatment 
especially, and its import will extend over a longer period of time 
than you may have supposed. 



LECTURE XXX. 



RECURRENT ABORTION FROM M AL-L ACTATION . 

Recurrent abortion f roai mal-lactation. Leucorrhoea the cause of impaired lacteal secre- 
tion. Loss of the nipples from erysipelatous inflammation. Anaemia from conjoined 
lactation and menstruation, Extraordinary lactation. 

Case. — Mrs. -, aged thirty, has had six children, the last 

three of which were still-born. She complains ot a choking sen- 
sation in the throat and a constant dull ache in the head and back. 
There is a free secretion of saliva amounting almost to ptyalism. 
Not having menstruated for four months, she supposes herself to 
be pregnant again. When her third baby was a week old, she 
was seized with a violent chill , which had the effect to stop the flow 
of milk entirely. It did not come again, but she was very ill for 
two months afterwards. She had nursed the first three children 
naturally, and had plenty of milk for them ; but there was no 
secretion of milk in either of the subsequent pregnancies. All of 
the still-born children survived the seventh month of utero-gesta- 
tion. She is very anxious to go to " term" with this one. 

The clinical history of women abounds in crises. We are re- 
minded by this case, that one of these crises may so extend its 
influence as to modify another, and indeed to change the whole 
subsequent health of the patient, 

I have no doubt that a sudden arrest of the secretion of milk 
may indirectly work mischief in subsequent pregnancies. Although 
this is not classed among the causes of abortion, or of still-birth, 
it certainly may predispose to such a mishap. This result is not 
infrequent in fashionable life, where infants are turned off for 
trivial reasons, and the flow of milk is suppressed by artificial 
means. And you should not forget that the " habit " of aborting 
may sometimes be entailed upon your patients in this way. 

The reason why this poor woman has failed to have a living child 
since her third baby was born is therefore evident. If her breasts 
had never filled ; if she had failed to furnish food for one and all 
of her first children, the case would have been different. The 
mere fact that she had never been able to nurse them would exclude 

487 



488 THE DISEASES OF* WOMEN. 

the morbid cause ot which I an* speaking-. But, when she had 
reared three, or even one of them in the natural way, and then 
experienced a sudden and complete arrest of this function (more 
especially within the first week of her next lying-in), the conse- 
quences were more lasting and serious. 

If your experience accords with mine you will he thoroughly 
impressed with the importance of non-lactation as a factor in the 
production not only of sub-involution and its usual consequences, 
but also of a variety of disorders of the function of reproduc- 
tion. It has often happened that the failure of a primipara to 
nurse her child, as she might and should have clone, has made her 
practically barren, as well as a confirmed invalid. This result 
may sometimes be ascribed to the formation of neoplasms, such 
as fibroids, which have developed insidiously, and which interfere 
mechanically with the evolution of the gravid uterus. Some- 
times it renders the womb so intolerant of the ovum as to cause a 
form of abortion which is classed as membranous dysmenorrhcea; 
and again it entails a chronic inflammation of the ovaries, which 
it is next to impossible to care. 

Even where the function of lactation is not entirely arrested 
by the contingencies with which it is beset, certain mischievous 
results may follow. So slight a mishap as the chill from which 
our patient suffered might, under peculiar circumstances, have 
laid the foundation for a recurrent abortion. In fact, there is no 
single symptom of the lying-in which is more significant, either 
in its immediate or remote effects, than the chill which may hap- 
pen at any time within the first month. Those of you who wish 
to study this subject very thoroughly should read the remarkable 
monograph of Dr. Stoicesco upon the nature and significance of 
the chill in the puerperal state.* 

Its proneness to affect the uterine lymphatic and the whole 
intra-pelvic circulation, causing inflammation and derangement of 
function during lying-in, explains the liability to such remote 
troubles as are now under review. This is one method at least in 
which the chill as a contingent of the puerperal state may become 
the predisposing cause of abortion. 

There are many diseases of women, besides those which are con- 

*Du Frisson (pathogenie et nature) sa valeur semeiologique pendant l'etat puerperal, 
etc., pp. 150. Paris, 1876. 



LEUCORRHCEA AND THE LACTEAL SECRETION. 481) 

tingent upon gestation, that are clue, perhaps very remotely, to the 
same cause. 

Naturally enough this knowledge of the case implies the possi- 
bility of helping our patient to carry her child to term, by pre- 
scribing for the effects of that chill, the arrest of the lacteal flow, 
and her subsequent illness. But, are our remedies retro-active? 
I have no doubt of it, if they are properly chosen. 

First we Avill give her a few closes of belladonna 3 for the angina 
and the headache. Then she will take phosphorus 6, twice daily, 
for a fortnight, and we shall see if she does not improve. 

[This patient, who reported from time to time, improved steadily 
upon the phosphorus. She took no other remedy, and went to 
term without any further accident. She was safely delivered of a 
healthy child, and was able to nurse it.] 

LEUCORRHCEA THE CAUSE OF IMPAIRED LACTEAL SECRETION. 

Case. — Mrs. , aged 30, of scrofulous diathesis, has one 

child, which is now two and a half months old. She has had 
leucorrhcea for more than two years. It showed no abatement 
-during pregnancy, and continued through her lying-in and lacta- 
tion. At birth, her infant weighed ten pounds ; now it weighs 
only eight pounds. Its digestive system has been constantly 
deranged, and its little life threatened by vomiting, indigestion, 
and diarrhoea. The mother's breasts have not been diseased in 
any way, but have remained plump, soft, and natural. The qual- 
ity of the milk, however, was impaired. It was thin, watery, and 
of a bluish cast. 

A fortnight ago the child was, by my advice, taken from the 
breast, and ordered good cow's milk, diluted in the proportion 
of one-third water to two-thirds milk. Immediately it began to 
improve and gain flesh, and it is now nearly well. The only 
treatment this patient has ever had for the leucorrhcea, consisted 
of harsh astringent injections of alum-water, tannin, etc. These 
expedients have had the effect to arrest the flow temporarily. 
She describes the discharge as milky, and says it is accompanied 
by more or less of aching in the vagina and itching of the pudenda. 
The flow is more profuse after exercise. It has been her habit 
heretofore to menstruate too freely and frequently. 

Leucorrhcea is sometimes very persistent. It may be associated, 
either as cause or effect, with a depraved and 

io S ^s eucorrh(Ea and scrofu ~ enfeebled condition of system. The worst cases 
occur in scrofulous subjects. In this class of 

patients there is a strong predisposition to glandular disease, and 



490 THE DISEASES OF WOMEN. 

leucorrhoea should properly be classed among the glandular affec- 
tions. Let us inquire into the significance of the fact that it is so 
frequently engrafted upon the scrofulous dyscrasia. 

In the lecture upon hsematogenesis, or blood-making, which you 
heard only last evening, my colleague, the professor of physiology,, 
directed your attention to the important function of the lymphatic 
glands, as related to that process. You were told that the chyle 
and lymph which are subjected to the action of these glands, are 
so changed thereby as afterwards to constitute a most essential 
part of the blood. The mesenteric glands manipulate the chylif- 
erous fluid which is en route for the general circulation. Both the 
superficial and the deep-seated lymphatics are designed to absorb 
any surplus of serum that may have been poured out in excess of 
the needs of the different tissues. They are the original physio- 
logical economists. They stamp their impress upon this fluid, and 
then pass it along into the blood-current again. This is the func- 
tion of lymphosis. As indicated in the lecture to which I have- 
just referred, it concerns the assimilation of the oleo-albuminous- 
element of the food. It is the first step in the process of histo- 
genesis or tissue-making. If this step is not properly taken, the 
blood becomes impaired in quality, and all the functions are likely 
to be implicated. 

Now this physiological knowledge is of practical application to 
the case before us. Scrofulous persons are unhealthy because this 
glandular system is predisposed to disease. Inflammation, or any 
of its consequences, may so impair the function of the lymphatics 
as to impoverish the blood, and even to render it harmful to the 
life-processes. Under these circumstances the albuminous princi- 
ple is not available for the repair of the tissues. It circulates as 
a foreign element, which must, in some way, be eliminated and 
expelled from the organism. It may find an outlet through the 
kidneys, or some other excretory apparatus ; but in escaping i& 
very likely to develop a catarrhal inflammation of one or another 
of the mucous membranes. The mucous secretions are changed 
in amount and quality. They become the vehicle for carrying off 
those very elements which are needed in nutrition, but which have 
been rejected because the initiatory step in the process of their 
assimilation was not properly taken. In political parlance, there 
is so much " red-tapeism," so much respect for method and prece- 



LEUCOKRHCEA AND THE LACTEAL SECRETION. 4U1 

dent, in the affairs of our bodily organization, that the other organs 
and textures will neither recognize nor appropriate this class of 
proximate principles, unless they have been identified and stamped, 
or acted upon beforehand. 

The same is true of those glands which are set apart for the 
elaboration of their particular products from elements contained 
in the blood. It is quite as impossible for the gastric glands to 
secrete the proper solvent for the food from blood, the quality of 
which has been impaired in the manner just indicated, as for the 
muscular and serous, or other tissues, to repair themselves out of 
a like material. The mammary glands do not form an exception 
to this rule. This woman's milk is impoverished and injurious to 
the child, because in the blood which was brought to them the 
breasts failed to find the materials out of which they could manu- 
facture a wholesome product. Those elements were drained away 
in the critical discharge from the glands and follicles of the vagina 
and of the uterine cervix. 

Moreover, in consequence of the mammary glands having become 

eliminative, as well as secretory, it is not impossible that some of 

these abnormal elements may also escape with 

Illness of the infant .from t ] ie m flfc f rQm t ] ie breasts. Such a DrOClUCt 

leucorrhoea in the mother. xr 

would be both non-assimilable and noxious. 
The infant would become impoverished and poisoned from nurs- 
ing it. It could not thrive upon such aliment. Hence the vom- 
iting, indigestion and diarrhoea which have resulted in the case of 
this woman's child. The rapid improvement in its health from 
changing its diet to good cow's milk confirms the view we have 
taken. 

In rare cases it sometimes happens that the nursing child 

becomes diseased in consequence of the mother's milk having 

been poisoned, through the absorption of drugs 

^indirect poisoning of the fa^ j iave L, een injected into the vagina for the 

purpose of arresting a leucorrhoeal flow. I am 
quite confident that I have seen more than one such infant in 
great suffering, and ill with an obscure disease, which was prop- 
erly chargeable to the acetate of lead, alum, tannin, etc., that had 
been used in the manner indicated. 

Reserving the differential diagnosis of uterine from vaginal leu- 
corrhoea for another lecture, I will call your attention to the sig- 



492 1HE DISEASES OF WOMEN. 

nificance of one or two objective symptoms presented in the case 
now under consideration. If this patient's flow, 
sterility" 6 Ieucorrhoea and which is sometimes profuse, and has continued 
for two years, came from the uterine cervix, 
in all probability she would have remained sterile ; for, as I 
shall doubtless have occasion to show you, this form of Ieucorrhoea 
is a frequent cause of barrenness. And, besides, had it been uter- 
ine, and not vaginal, there would surely have been a partial or 
complete arrest thereof during pregnancy. Sometimes, however, 
both varieties may exist conjointly, or they may even alternate in 
the same patient. 

Treatment. — In all cases of Ieucorrhoea which are incident to 
gestation and lactation, you should bear in mind that the blood is 
being drained of its assimilable material for the growth of the 
■offspring. For this reason it is sometimes quite impossible to cure 
the affection radically until these functions have ceased by limita- 
tion. In either case, indeed, the Ieucorrhoea may be critical, and 
it might therefore be injurious either to mother or child to arrest 
it while these processes are going on. This is a forcible argument 
against the use of astringents which are designed to seal up this 
flow, and to close a species of safety-valve to the general economy. 
There are two reasons that may justify, and even necessitate, 
the weaning of the child for the cure of a Ieucorrhoea which is 
incident to the nursing period. If the draught 

Weaning the child. 1 1 , 

upon the mother s resources while nursing, 
undermines her strength, it furnishes a cause for this disease 
which is constant in its operation, and which can only be removed 
by putting the child away from the breast. And weaning is still 
more strongly indicated if the child was large and plump at its 
birth, and the Ieucorrhoea continued during pregnancy also. Be- 
sides, the safety and welfare of the infant may require that it 
shall be brought up artificially, rather than upon the unhealthy 
milk that is furnished by the mother. 

Not unfrequently the cure is half performed when you have 
prevented a waste which only weakens the mother and injures 
the child. Stop the leak, and her strength may soon return. 
For it is a condition of healthy glandular activity, that the blood 
must be nourishing and stimulating to the glands as well as to 
■other bodily organs. 



LEUCORRHCEA AND THE LACTEAL SECRETION, 493 

It is no less important to select a suitable diet for this patient, 
than to decide upon the appropriate remedy for the symptoms 
presented. Indeed, the rational method of pro- 
cedure would be, first, to supply the physio- 
logical conditions that are requisite to health, in order that our 
curative agents may afterwards act more promptly and efficiently. 
Granted that, in the case before us, the function of the mesenteric 
glands is so impaired that they fail to effect the proper changes in 
the peptones brought to them from the bowel. The indication is 
to choose such an aliment as by their aid may be assimilated. The 
whites of eggs, lean meat, sea-food, as oysters or other shell-fish, 
or good fresh milk, are more easily digested and disposed of, and 
also more nourishing, than a mixed diet largely composed of fatty 
substances, soups, and the like. It is quite as necessary to dis- 
criminate carefully in this class of diseases, and to allow only such 
food as will be kindly received and appropriated, as it is in the 
case of the infant, whose digestion is very weak, and whose ali- 
mentar}^ system is easily deranged. Sometimes the vegetable acids 
are not only grateful, but really beneficial. The patient may eat 
grapes, oranges, tomatoes, or baked apples, or she may drink a 
mild wine, or an occasional glass of lemonade. Now and then the 
most excellent results are obtained from travel, partly because of 
the change of scene and surroundings, but also, as the phrase is, 
"from change of pasture." The same food, cooked differently, 
may be more acceptable to the stomach of an invalid, and less 
harmful in every way, than if she had remained at home and eaten 
it from the same dish and table as before. 

But let us inquire if there is any means whereby the important 

function of lymphosis may be stimulated and encouraged. The 

salts of potassa, soda, lime, alumina, baryta, 

Lymphatic stimulants. . , . 

iron, iodine, ammonia, phosphorus, and other 
earths and metals, are all more or less intimately related there- 
with. As prepared by the pharmaceutist, or in the form of 
mineral waters in the great laboratory of Nature, they have long 
been emplo}~ed for the cure of all the principal disorders of nutri- 
tion. And the almost universal record of the good results so 
frequently obtained from them, leads us to conclude that empirical 
observation cannot have gone very far astray in this matter. The 
hint, at least, is significant. Clinical experience confirms their 



494 THE DISEASES OF WOMEN. 

value in the treatment of leucorrhoea. A majority of the reliable 
remedies for this disease are of mineral origin. And each of 
them has a specific, pathogenetic, and curative relation to the 
lymphatic glands. It is for this reason, doubtless, that they are 
most serviceable in the treatment of scrofulous and catarrhal affec- 
tions of almost every kind. 

Although these clinical generalities are both analytical and 
suggestive, they should not be allowed to substitute a more care- 
ful selection of the appropriate remedy or remedies. We must 
choose from among all those named, and many more beside, the 
proper simillimum for the more prominent . symptoms complained 
of. If you will turn to the pathogenesis of calcarea carbonica 
you will find it. The indications for this most excellent remedy 
are so positive and almost mathematically exact, that we need 
look no further. It is called for by the milky leucorrhoea, with 
aching in the vagina, and itching in the pudenda, with increased 
flow after exercise, and also in the case of a woman who is subject 
to a too copious and oft-recurring menstruation. 

In prescribing the calcarea carbonica in similar cases, and in- 
deed ordinarily, my own preference is for the third decimal tritu- 
ration. And, while I do not question the efficacy of the medium 
and higher preparations thereof, my experience is certainly opposed 
to the theory which holds that no curative effect can be obtained 
from this remedy unless it be given in the sixth or a higher 

potency. Mrs. will take one-and-a-half grains of the third 

trituration of the calcarea morning and evening, and report at the 
end of a week. 

LOSS OF THE NIPPLES FROM ERYSIPELATOUS INFLAMMATION. 

The notes of the following remarkable case were sent to me by 
one of our cleverest graduates, Dr. E. E. Holman, of Warren, 
Illinois, in June 1880. 

Case. — Mrs. H., a prhnipara who was confined two months ago 
by a midwife, seemed at first to do well ; but in a few days the 
nipples became perfectly raw from nursing. The midwife did 
nothing for them. The application of the child to the breast, 
caused the mother so much pain that her husband was obliged to 
hold her while it nursed. This process was continued until both 
nipples came oft', after which the milk flowed constantly. Ery- 
sipelatous inflammation set in which spread over both breasts and 



ANAEMIA FROM LACTATION, ETC. 495 

down to the hips, wherever the milk kept the clothes wet. The 
baby had been weaned. 

The inflammation was almost entirely subdued by the internal 
use of belladonna. The patient had a good appetite and her gen- 
-eral health was fair, although she is of a scrofulous diathesis, and 
her lungs are not very strong. 

Glass"nipple-shields were used to protect the breasts from the 
•constant flow of milk. They were kept in place by a closely fitting 
waist, which was worn day and night. The local application of 
camphorated oil was persisted in until there was no further secre- 
tion from the glands. At first, however, plain cosmoline was 
*ised until the surface had healed over. 

The nipples — or rather what remained to tell that they had once 
existed — bathed as they were in the milk, did not heal until lacta- 
tion had ceased, when they healed rapidly under the topical appli- 
cation of pulverized gum arabic. (I have never failed with this 
as an application for sore nipples, even when other means have 
been ineffectual.) 

After the erysipelatous inflammation had been controlled by 
the employment of belladonna, calcarea carb. 6,. four times per day 
was the only remedy given. The menses came at the proper time, 
and the patient enjoyed as good health as ever before. 

ANEMIA FROM CONJOINED LACTATION AND MENSTRUATION. 

Case. — Mrs. M., aged twenty-six, has been ill for ten months, 
or since her only child was two months old. She complains of 
pain in her chest, and of a copious leucorrhceal flow which is worse 
in the inter-menstrual period, and is aggravated by the least 
exercise. Her menses are regular, not too copious, but have con- 
tinued to recur since the babe was two months old, she nursing 
the child until its death, at six months. China 3, four times a 
day. 

May. ly. She is feeling better, but has some chilly, creeping 
sensations. The leucorrhcea is less free. China 3. 

May 26. On local examination in presence of the sub-class, we 
find the uterus measuring four inches in depth, and a slight endo- 
cervicitis. China 3. 

June 2. She presents herself with a good report having, 
" nothing to complain of." She feels strong and well again. Her 
color is very much improved, and she is advised to report for 
another local examination after the next monthly period. 

It is practically burning the candle at both ends for a mother to 
persist in nursing her child while she is menstruating. This 
woman's menses returned before the involution of the uterus 
was completed. When they came, the natural and necessary effect 



496 THE DISEASES OF WOMEN. 

of lactation to divert the blood from the pelvis, and to stimulate 
the uterine contraction, like a battery, was suspended; besides, 
the double drain in the flow of the milk and the menses, reduced 
her strength and impoverished her blood, if it did not actually 
poison her child. The increased depth of the uterus which you all 
can verify, is the result of these combined causes. You have seen 
that, in this case at least, it does not depend upon a laceration of 
the cervix. 

UNILATERAL NEURALGIA FROM PROLONGED LACTATION. 

Case.— Mrs. C, aged twenty-eight years, has had tw T o children, 
1 he youngest of Avhich is a large, strong boy, now eighteen months 
old. She still nurses this child, but only on the left breast, the 
milk having disappeared from the right breast only because the 
child was always applied to the other one, a habit which grew 
out of his lying and dragging at the nipple all night. The 
patient is very weak, and, in the morning especially, sometimes 
ieels so exhausted that she can scarcely get up. When her baby 
was four months old she began to menstruate, and this function 
lias repeated itself, at first irregularly, but of late the flow has- 
been regular, although more copious than it was formerly. 

Her chief complaint is of a pain in the left chest passing 
beneath the breast and extending through the thorax to a point 
below the corresponding scapula. It also passes down the left 
arm, which sometimes feels so weak that she can scarcely lift it. 
This pain, which she has had for six months, is sharp, catching 
and spasmodic in character, unaflectecl by respiration, not at- 
tended by cough, palpitation or dyspnoea, but is always aggra- 
vated by the child's nursing, especially at night. She is pale, 
sallow and dragged out, with the appearance of having been ill 
for a long time. 

Here we have an illustration of the fact that one condition of 
secretory activity in the mammary gland consists in the applica- 
tion of the child to the breast. This woman nursed her baby 
exclusively on the left side because it was more convenient, as it 
always is, and because the little youngster could lie there and pull 
at it all night long. 

It also confirms what I have so often told you of the ill effect 
of nursing and menstruating at the same time. The evil conse- 
quences are not always identical, but they are inevitable. In the 
case which has just left us, there was a decided anaemia; but here 



EXTRAORDINARY LACTATION. 497 

we have a local and persistent neuralgia that is directly referable 
to prolonged lactation under peculiar circumstances. 

The points that I want to make for you are these: (1), that a 
little reflection will prevent you from confounding snch a case as 
this with pulmonary or cardiac difficulties; (2), that the exercise 
of a little good sense in the regulation of the patient's habits is 
indispensable to a cure; (3), that since we cannot arrest the 
menstrual function at will, we must wean the child to stop a 
further waste; and (4), the affiliation of the remedy is an affair of 
secondary importance, for when the proper conditions for the 
woman's health are supplied, the neuralgia will usually disappear 
of itself. 

I will close this lecture by citing the following case which was 
reported in the JST. E. Medical Gazette for April 15, 1867, by Dr. 
Wm. Pearson, of Mass. ; 

EXTRAORDINARY LACTATION. 

Case. — Mrs. D., residing in Vermont, aged twenty-eight, had 
been married ten years, and enjoyed good health, but had never 
borne children , or had any signs of pregnancy. She began to have 
morning sickness in August, 1854, and menstruation gradually 
ceased three months later. In January following, the morning 
sickness subsided ; but she had a feeling of general languor, and 
soreness in the region of the right ovary. She had " motion 
plainly to be felt and seen," she said. About this time the mam- 
mary glands began to have more than the usual tenderness and 
fullness, and in February the breasts were full of milk to over- 
flowing; and in fact, she had all the usual signs of pregnancy in 
the last stage. 

About the first of March, she was " taken with slight flowing," 
which continued a week or more attended with pains like those 
of labor; and a physician was called to attend to her case, which 
he thought very peculiar. These symptoms gradually passed off; 
and, in about three weeks, she had a similar attack of pain and 
flowing. The secretion of milk continued as before; but she had 
no expulsion of any substance from the uterus, either this time 
or ever afterwards. 

Subsequently her usual monthly periods became established ; 
but she continued to have a large flow of milk, and was obliged 
to have it drawn by some means. 

In the course of a few weeks, a child was presented to her by a 
gentleman who had the misfortune to lose his wife in confine- 

32 






498 THE DISEASES OF WOMEN. 

ment. She nursed the child from month to month, and gradually 
diminished in size, and recovered her usual health and strength. 

The lady is still living, in good health, with the exception of 
occasional attacks of colic, and severe spasms in the region of the 
liver, probably from biliary calculi. In a practice of more than 
thirty years, I have never happened to see another such case, 
and how to account for this I know not. 

This was evidently a remarkable, and a very unusual freak of 
Nature, for which, since the function of ovulation was intact 
meanwhile, no valid reason can be assigned. If the uterus had 
contained a foreign body, the delivery of which had been brought 
about as in natural labor, there would have been a physiological 
reason for it ; but the circumstances as related cannot be ex- 
plained in any such way. 



Part Seventh. 



THE DISEASES OF THE CLIMACTERIC. 



LECTURE XXXI. 



THE CLIMACTERIC PERIOD. 



The Menopause; the disorders of ,— the diseases that are cured, by it. Symptoms; Case, 
diagnosis ; prognosis ; treatment. Hysteria at the climacteric. Hysteria in a woman 
aged sixty. 

The period at which the menses cease is sometimes styled the 
" change of life," the " grand climacteric," the " critical age," the 
" turn of life," and the menopause. It indicates the close ol a 
woman's menstrual, and therefore of her sexual life. When that 
life has continued for thirty years or more, with its monthly 
vicissitudes, which have been interrupted only by pregnancy, lacta- 
tion or disease, it is natural to suppose that its final arrest will be 
beset by contingencies of a peculiar kind. The diseases of the cli- 
macteric possess a peculiar interest for the physician, more especially 
because they are intricate and difficult of cure, aud because they 
concern a very important class of his patients. 

If it is important to tide a patient over the difficulties that are 
proper to the crises of which we have spoken, it is none the less 
so to protect her at the climacteric. The clinical interest which 
centres in her as a sexual being culminates at this period, and there 
is no better evidence of our civilization, and of our professional 
capacity than is to be found in the care which we bestow upon 
women at this time, and under these circumstances. 

The age at which this period arrives in woman varies as much 
in different individuals as does that which dates the advent of 

- . puberty. Indeed it bears such a oreneral rela- 

Varying age. . ° 

tion to the early or late establishment of the 
menstrual function that we ordinarily estimate from puberty to 



500 THE DISEASES OF WOMEN. 

determine when the catamenia should naturally cease. Thus, the 
usual duration of menstrual life is thirty years. If our patient 

was " unwell " for the first time when she was 
^Duration of menstrual i^ thirteen years old, and we add thirty to that 

number, we shall have forty-three years as the 
most natural limit for the return of the monthly cycle. If, 
instead of beginning at thirteen the function had failed until she 
was fifteen, then she would most naturally continue to menstruate 
until she had reached the age of forty-five years. 

But this calculation is approximative, and not exact. We must 
make allowance for modifying circumstances of various kinds, 

among which hereditary peculiarities are, per- 

Exceptions. 

haps, the most marked. I here are families in 
which all the women cease to menstruate prematurely at as early 
an age as thirty, others at thirty-five, and still others in whom the 
menopause is adjourned until fifty, or even to the 60th year, when 
it degenerates into a species of sexual haemorrhage. In these 
cases the advent of the change of life bears no particular relation 
to the age of the individual at the time that puberty was estab- 
lished. It not unfrequently happens that those who begin to 
menstruate the earliest continue to do so for a longer period than 
those who began later in life. 

Physiologically considered, the " change " which closes and 
terminates a most important function of the female economy, is 

truly an eventful and a marvelous one. It must 

Importance of the change. . 

work such a complete revolution as to invest 
this crisis with numerous contingencies. For this function, which 
represents the maternal instinct and relation, which made it pos- 
sible for the woman to become a mother, which was suspended 
while the child was being developed in utero, and while she 
nourished it at the breast ; and wdiich was restored again in due 
season, is not one that can be begun, continued for so many years, 
and then stopped, without great expense and risk to the general 
organism. 

Hence we find that the approach of the climacteric predisposes 

women to various diseases which are of a more 
Predisposition incident to or } ess se rious nature. And, w r hat is very 

this period. / J 

strange, it not unfrequently happens that the 
disease from which they may have suffered at puberty re- 



THE CLIMACTERIC PERIOD. 501 

turns. It is so in the case before us. The class of affections 
which are most likely to recur in this manner are eruptive and 
nervous disorders, and haemorrhages from certain mucous mem- 
branes. In cases of this kind, it may happen 
tert is mr s retum nt to pu ~ tna ^ manv years have elapsed without any sign 
of the difficulty, but when this change begins 
to take place the first symptom noticed is the reappearance of 
the old enemy. Very nervous and plethoric women are more 
likely to suffer in this manner, and indeed to be ill, at the change 
of life, than those who are of a lymphatic temperament. 

But in this respect the menopause is not absolutely or always 
in relation with puberty. Very often the experiences that have 

intervened since the woman first began to men- 
New disorders induced. 

struate have so changed her nature that she has 
acquired a predisposition to other and different diseases. Preg- 
nancy, labor, and lactation, leave their impress upon her organi- 
zation, and it is as impossible for her youthful susceptibilities 
always to return, as it would be for her to become the same in 
feeling after the change of life that she was in her girlhood. 

Another peculiarity worthy of note is that many diseases are 
cured, or disappear in consequence of the climacteric. The ova- 
rian atrophy and paralysis removes a constantlv 

Old diseases cured by. . „ ,. ™ J 

recurring source of disease. The monthly cycle 
and its attendant excitement of the nervous, vascular, and 
glandular systems is withdrawn. A season of continued quiet, 
and comparative tranquillity supplies a favorable condition for the 
restoration of health. And when the critical period has passed it 
is found to have been the scape-goat of a thousand ills. Slender 
women may become corpulent and even obese, bed-ridden invalids 
get up and walk, and an entire and radical change of physical 
condition is the consequence in those who escape the perils of this 
period. They enter upon a new phase of life, with new hopes 
and relations towards the present and the future. 

Symptoms. — The manner of approach of the critical period 
varies in different individuals. With some women the change is 
abrupt, but with the majority it is more prolonged and gradual. 
Not infrequently the flow becomes intermittent, or, rather, the 
periods become irregular. One, two, three, or perhaps six 
months, and sometimes a year or moie, may elapse between them. 



. r >02 THE DISEASES OF WOMEN. 

In many cases the} 7 are too frequent, as well as too profuse, for a 
season, and afterwards are more tard}^ and abnormal in this, 
respect. 

In a considerable proportion of cases the amount of the flow 

lessens gradually, so that it may finally come away drop by drop, 

or until there is nothing of it left. But as the 

Haemorrhage. 

change approaches, many women find them- 
selves flowing more freely than ever before. Indeed, the tend- 
ency of the catamenial discharge to develop into a haemorrhage is 
often observed. Out of 500 women at the change of life, Tilt 
observed that 208 had haemorrhages of various kinds. Of these, 
IS 8 had either a single terminal flooding, or successive floodings.* 
Other forms of haemorrhage, which are in a sense vicarious of 
the monthly flow at the climacteric, are haemorrhoids, entorrhagia, 
epistaxis, haemoptysis, cerebral haemorrhage and apoplexy, hsem- 
atemesis, haematuria, bursting of varicose veins, bleeding from the 
ear, and cutaneous ecchymosis. In plethoric women these losses 
of blood are in a sense critical, and although they are often dan- 
gerous in themselves, yet as a kind of safety-valve, they are 
sometimes salutary. 

The sudden arrest of the accustomed flow, when the change 
comes on abruptly, and more especially in those who are in good 

health, is often the occasion of alarm with such 

Simulates pregnancy. 

persons lest the} r be pregnant. I his suspicion 
finds apparent confirmation in the coincident gastric derange- 
ments that not unfrequently ensue. There is something resem- 
bling morning sickness, caprices of appetite, a sense of fullness 
and discomfort, and pelvic bearing-down and aching which 
women recognize as very similar to, if not identical with the 
symptoms of early pregnancy. You will certainly be consulted 
in cases of this kind, and in making a diagnosis should not forget 
that some women cease to menstruate as early as the twenty-fifth 
year. 

Sometimes the most violent, and again the most persistent and 
intractable indigestion, colic, diarrhoea, haemor- 

Alimentary symptoms. . . 

rhoids, dysentery or constipation, come with the 
first symptom of the menstrual decline. In many cases, these 

*The Change of Life in Health and Disease. By Edward John Tilt, M.D., etc., 
London, 1867, page 65. 



THE CLIMACTERIC PERIOD. 5(Jo 

attacks are self-limited, and subside of themselves when the crisis 
has finally passed. In a few they supplement the catamenial 
flow, and may pass into the chronic form. 

The circulation is very irregular, as is shown by flushes of heat 
in the face and elsewhere, local congestions to the head, giddi- 
ness, blushing and discoloration of the skin, 
Disorders of the drcuia- coldness, tingling and numbness of the ex- 

Iion. ° ° 

tremities, sudden outbreaks of perspiration, 
chilliness, rigors, and active haemorrhages. 

The nervous symptoms and sequelae of the climacteric are 

marked and sometimes very troublesome. In degree they vary 

from the slight mental perturbations, vulgarly 

Nervous symptoms. -i t i n i ?, 

styled " the fidgets, to the most profound con- 
vulsions and paralysis. Headache, vertigo, nervous irritability, 
pseudo-narcotism, self-absorption, insomnia, jactitation, palpita- 
tion, dyspnoea, horrible dreams, fainting, erethism, depression, 
debility, twitchings, spasms, mania, and full-fledged hysteria are 
by no means uncommon at this period. Either of these affections 
may precede, accompany or follow the cessation of the menses. 
In many cases the disorder is ephemeral ; but in others it becomes 
seated and confirmed. Spasmodic affections are very apt to con- 
tinue, and to take on a regular periodical type, which is most 
difficult of cure. The ganglionic nervous system is always impli- 
cated. 

There is a form of epilepsy which is not unusual at this period. 

I have seen several cases of the kind that were 
• in no way connected with the hereditary form 
of this disease. Only yesterday I was consulted by my friend, Dr. 
W. R. McLaren, for the relief of the following 

Case. — Mrs. , aged fort} T -five, is now passing through the 

grand climacteric. The menses recur every four to six months. 
They are quite profuse. About every seven weeks she has the 
epileptic seizure. There is no very strong muscular contraction 
or rigidity. The face is pale, and during the paroxysm there is 
stertorous breathing, with foaming at the mouth. The fit, during 
which she is quite oblivious to everything external, lasts about 
four minutes. After it she sleeps for three-fourths of an hour. 
The change of life commenced with her one year ago, at which 
time she first began to have the epileptic paroxysms. Epilepsy is 



504 THE DISEASES OF WOMEN. 

not hereditary in her family, although her mother also had fits at 
the change of life. 

Disorders of the nerves of special sense are not infrequent. 
Deafness, blindness, aphonia, loss of the sense of taste or of smell, 
and of tactile sensibility in various portions of 
seSes° rdersofthespecIal the- skin, are among the more common of these 
affections. These complications are most apt 
to occur in weakly, nervous, debilitated women in whom, for some 
reason, the climacteric is very much prolonged or exhaustive. 

The respiratory system comes in for its share of the contingent 
ailments. Those women especially who are predisposed to pecto- 
ral complaints, who inherit this bias, and who 
sy Sem asesoftherespiratory have suffered some of the consequences of 
incipient organic disease of the lungs at or 
before puberty, are most likely to have something of the kind at 
the climacteric change. Perhaps the first thing noticed is a more 
or less copious spitting of blood, or a nervous, irritating cough, 
which by and by settles into a confirmed habit, and is accom- 
panied by free expectoration. In some cases these symptoms 
develop into a rapid decline, and the patient may not live more 
than a very few weeks. In others they subside of themselves 
when the first cause is removed, and the menstrual crisis is safely 
over. In not a few instances the boasted cures of phthisis pul- 
monalis are really to be ascribed to the fact that such cases as 
these are self-limited, and frequently get well of themselves. 

But, as you would suppose, it is the generative function and 
the sexual organs which are most seriously disordered in conse- 
quence of the final cessation of the menses. 
Disorders of the genera- xhus Dr. Tilt* found that of 500 women at the 

tive system. 

change of life, 463 suffered from uterine affec- 
tions. Among these contingent disorders are uterine cancer and 
catarrh, cervical inflammation and hypertrophy, uterine ulcera- 
tion, haemorrhage, hysteralgia, leucorrhcea, displacements, tumors, 
hydatids, polypi, and fibroids. Either or all of these diseases are 
more serious if the patient has already suffered from them. 

Other complications are ovaritis, ovarian induration, atrophy 
and paralysis, the development of cystic tumors, and of ovarian 

*Op. citat., p. 82. 



THE CLIMACTERIC PERIOD. 505 

abscess, and hematocele. And still another disease of the 
generative system, properly speaking, is cancer 
of the breast, the development of which appears 

in many cases to be hastened by the permanent arrest of the 

menstrual secretion. 

Women sometimes suffer from a species of rheumatism and 

others from neuralgia which worries them exceedingly, and may 
perhaps wear away their remaining strength very 

Rheumatism and neuralgia. . rv» • • 

rapidly. Again these affections are combined, 
and either or both of them may be located within the pelvis. The 
arrival of the critical period may act as an exciting cause, and 
really occasion an attack of rheumatism in one who not only has 
never had it before, but who was thought to be free from any pre- 
disposition to it. I could cite you many cases of this kind, but it 
must suffice merely to call your attention to the fact itself. 

Prognosis. — Where serious diseases occur at the climacteric, or 
follow it almost immediately, you will be puzzled in your prog- 
nosis. Eminent authorities are of opinion that 
The general health the f^g ovarian activity is commensurate with the 

best criterion. «/ 

constitutional vigor ; and that, as a rule, life is 
longest in those women in whom puberty is retarded and the 
menstrual function most prolonged. Therefore, it will be a safe 
criterion upon Avhich to base an opinion if we say that the 
patient's previous health (especially in so far as ovulation is con- 
cerned) has been good or ill, habitually. If she has been weakly 
and sickly, and suffered from menstrual derangements, such as 
dysmenorrhea, menorrhagia, and amenorrhcea, or her nutritive 
resources have been sapped and drained by a chronic leucorrhcea, 
or diarrhoea, or mal-medication, or starvation, whether mental, 
moral or physical, the case is not of the most hopeful kind. The 
same is true of the bad effects of scrofulosis, and of too rapid 
child-bearing, as tending to undermine the general health and 
vigor, and to leave the patient a more easy prey to the contingen- 
cies that beset the menopause. 

We are therefore compelled to make due allowance for previous 
ill health, and to qualify our prognosis ; for it is a crisis through 
which the woman must pass, and whether she will survive it or 
not, will depend very largely upon the stock of strength that she 
has in reserve to be°in with. 



50 J THE DISEASES OF WOMEN. 

Critical catamenial haemorrhages are dangerous, not because, 

as the ancients believed, that certain poisonous matters from the 

menses are retained in the blood-current, and 

Cause of the danger. i -i -i • • it i 

need to be eliminated, but because ol an over- 
whelming afflux of blood to a delicate tissue or organ, which mav 
soon result in disorganization and death. 

If the cessation of the periodical flow shall re-act upon the 
lungs, and light up the tuberculous diathesis, it will not be safe 

to promise to cure the patient. And so, also, 

The tuberculous diathesis. pi-txi 

ot the alimentary disorders, ot which 1 have 
spoken ; for, although some of these utero-intestinal affections 
subside of themselves, when the menses are entirely disposed of,, 
still in many other cases they only run a more rapid and fatal 
course. 

Treatment. — The critical period, therefore, is beset with so 
many dangers that its treatment becomes a very important mat- 
ter. The first thing to be done is so to regulate 

Hygienic rules. 

the habits and surroundings 01 the patient as to 
protect her against these dangers. The state of her mind, the 
amount and variety of her physical exercise, and her food, must 
be prescribed and regulated according to the rules of hygiene and 
of good, sound common sense. Nothing wears upon a woman who 
has reached the turn of life like a want of sleep, of rest, and of 
freedom from the petty cares and annoyances which she could 
once overcome by her own strength of will. 

She should be encouraged and stimulated by cheerful society,, 
and pleasant intercourse with a few friends. Her thoughts should 
not be introverted. She should not be permit- 
ted to brood over such reflections as will make 
her nervous and wretched, but should become interested in the- 
welfare and happiness of others ; for this is the line of thought 
that henceforth must engage her attention. 

Especially should you guard against the development of any 

disease to which she is predisposed. If she is liable to hsemor- 

rhagic attacks from plethora, let her diet be 

Guard against hereditary p i a i n an d unstimulating, her habits as active as 

predispositions. -L © ' 

possible within the limits of prudence, and give 
her such remedies (according to their specific indications) as aco- 
nite, belladonna, veratrum vir., gelseminum, bryonia, or ipecacu- 



THE CLIMACTERIC PERIOD. 507 

anha. If, however, the haemorrhage is passive, and the result of 
an anaemic or vitiated habit, you may consult 

For the haemorrhage. . .-.,. 

the merits ot nitric acid, china, arsenicum alb., 
secale cor., sabina, crocus, trillium, erechthites, pulsatilla, ferrum 
met., and carbo vegetabilis. Cool acidulated drinks ought always. 
to be preferred in this class of cases. Tea and coffee should be 
interdicted, and so, also, should very active or violent exercise. 

Next to this tendency to haemorrhage, which is always alarm- 
ing and frequently dangerous, especially at this time of life, the 
possibility that the patient may pass almost 
hthLis he tendency t0 insidiously into a decline from tuberculosis 
in some of its forms, renders it necessary to 
antidote this predisposition whenever it exists. For this pur- 
pose certain precautionary measures are requisite. A limited 
amount of exposure is not necessarily harmful, but care should be 
taken that these patients incur no risks in this regard. They 
should not be suffered to take cold, to get the feet wet, to go out 
in a storm, to wear insufficient clothing, no matter how fashion- 
able, or to talk or to sing too much and too long at one time. 
They should keep in from the night air especially, and not be 
permitted to sit in the open air, as many women are in the habit 
of doing. Such a patient should not be removed from her old 
home into a new house, for example, in which the walls are not 
dry. In brief, without being fussy, she should take unusual care of 
her health at this period, for a slight indiscretion, or an otherwise 
trifling cold might act as an exciting cause for the development 
of a latent disease that would soon carry her off. 

The remedies to be thought of in this connection are calcarea 
carb., calcarea phos., sanguinaria, phosphorus, stannum, mercurius 
jod., kali jod., kali brom., kali carb., hepar sulph., lachesis, sepia, 
lycopodium, nitric acid, ignatia, bryonia and silicea. The greatest 
possible care should be taken to recognize and to remedy the first 
symptoms of tuberculosis in a woman who is passing the critical 
period ; for if this is done there is little doubt that much trouble 
and suffering may be spared, and her life prolonged. 

The symptoms of coincident digestive disorders may be treated 
upon specific indications, always giving pref- 

For the digestive disorders. L r J ° ° L 

erence, however, when possible, to those reme- 
dies that have a curative relation to the generative, as well as 



50o THE DISEASES OF WOMEN. 

to the alimentary function. Nux vomica, colocynth, arsenicum 
alb., mercurius, pulsatilla, natrum mur., bryonia, calcarea carb., 
cocculus, veratrum alb. and veratrum vir., chamomilla, sulphur 
and belladonna belong to this class. The diet should be regulated 
with the greatest care. 

The wonderful influence of aconite over most of the derange- 
ments of the circulation at the climacteric, has long been known. 

It is an invaluable and almost indispensable 
ciSiadon disorders ° f the remedy. Other available remedies of this sort 

are veratrum viride, gelseminum, and bella- 
donna. They are not only indicated physiologically and patho- 
gen etically in many cases, but the indication includes their special 
relation to disorders of the sexual system, more particularly to 
such as depend upon certain crises in the uterine and ovarian 
circulation. For the " flushes" and flashes of sudden heat, which 
constitute the most troublesome symptoms in milder cases, Dr. 
Madden recommends lachesis, either in the sixth or twelfth dilu- 
tion ; Dr. John F. Gray, sanguinaria ; and Dr. Trinks, sulphuric 
acid. You will find the indications for these and other remedies 
in Dr. Richard Hughes' excellent work on Therapeutics.* 

The nervous epiphenomena demaucl such remedies under 
almost the same identical indications, as would be prescribed for 

them if they were incident to the more com- 

For the nervous symptoms. 

mon menstrual disorders, as tor example, dys- 
menorrhea, amenorrhea or menorrhagia. Belladonna, ignatia, 
hyoscyamus, coffea, chamomilla, moschus, pulsatilla, caulophyl- 
lin, macrotin and senecin, are most freely indicated. 

And so likewise of diseases of the generative organs that are 
incident to the critical period. The rules which I have so fre- 
quently repeated with reference to their medi- 
For the disorders of the ca j anc j surgical management should be carried 

generative system. © o 

out in practice with even more than ordinary 
•care and skill. Whatever can possibly interfere with the 
structural changes which result in the atrophy of the ovaries and 
the uterus, as a part of the critical process, should be removed. 
For these structural changes, brought about through fatty meta- 
morphosis, really pertain to the period through which the patient 

* A Manual of Therapeutics, by Richard Hughes, L.R.C.P. Ed., etc., etc., N. Y. 
1869, page 455. 



THE CLIMACTERIC PERIOD. 501) 

is passing, quite as decidedly as the cessation of the flow itself. 
Since it might therefore interrupt this retrograde metamorphosis 
of the tissues if inflammation were established in them, you should 
see to it that such a contingency is averted ; or if it has already 
be^un, to cure it and remove its consequences as speedily as 
possible. 

For the rheumatic and neuralgic complication, macrotin, rhus 
tox., atropine, the valerinate of zinc, mercurius, 

For rheumatism and L J 

neuralgia. and similar remedies will be required. 

THE COMPARATIVE FREQUENCY OF VARIOUS DISEASES AT THE 

CLIMACTERIC. 

At a late meeting of the Clinical Society Dr. B. L. Reynolds 
presented a table of fifty cases drawn from my clinic, illustrating 
the date of the menopause and showing the relative frequency of 
the diseases that accompany and follow it. 

Of these fifty cases, it will be observed that the age at which 
menstruation ceased, was below forty in two cases ; between forty 
and forty-five, in fitteen cases ; between forty- 
five and fifty, in twenty cases : between fifty and 
fifty-five, in thirteen cases. In one instance, the change of life 
occurred at fifty-six and in another at fifty-five. 

Of the diseases from which the patients were suffering when 

they came to the clinic,, and which were post-climrcteric, there 

Avere seven cases of dyspepsia, six of apoplexy, 

Relative frequency fiye of rl ieumatism, four of procidentia of the 

of disease. L 

uterus, three of headache, two of anasarca, two 
of gastritis, two of epithelioma of the cervix, two of prolapsus 
uteri, and one each of asthma, epistaxis, bronchocele, Bright's 
disease, dyspnoea, papular eruption, incipient paralysis, hemiplegia, 
hemorrhoids, haemoptysis, spinal irritation, tuberculosis, uterine 
epistaxis, metrorrhagia, ovarian dropsy, uterine fibroid, and chronic 
vaginitis. 

Although this table might have included many more cases, it 
serves to illustrate the relative frequency of diseases that occur at 
this particular period, and will give a good idea of what I shall be 
privileged to show you in this department of my clinic. Dyspepsia, 
rheumatism, etc., are as certainly modified by the menopause as 
they would be by puerperality if they occurred after child-birth. 



510 



THE DISEASES OF WOMEN. 



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THE CLIMACTERIC PERIOD. 511 



HYSTERIA AT THE CLIMACTERIC. 

Case. — Mrs. S , a strong, healthy-looking Avoman of 50 

relates the following history: She was taken ill while pregnant 
with her sixth and last child, fourteen years ago. This illness she 
attributes to neglect and unkind treatment on the part of her hus- 
band. Despite much trouble, suffering and anxiety, she went to 
term, and her child is still living. Her chief symptoms were a 
feeling as if she were dying, with great prostration, sinking, chok- 
ing at the throat, and partial unconsciousness. She would weep 
and sob for hours together, and her gloomy feelings could not be 
dissipated. These attacks came irregularly, but increased in 
severity towards the close of gestation. 

Two years later an eruption resembling " salt rheum " made its 
appearance on the right arm, above the elbow, and on the same 
side of the neck. The cropping out of this eruption, which is 
w r orse in cold weather, was followed by manifest relief of the ner- 
vous symptoms. She soon remarked that when it was out most 
frequently, she felt best in other respects, and vice versa. This 
alternation has continued for twelve years. Whenever the erup- 
tion disappears, the nervous symptoms are very distressing. 

Menstruation continued regularly until four years ago, the 
patient at that time being forty-six years old. It then began to 
be irregular, sometimes being absent for two, three, or even four 
months, and when it returned, it was liable to be profuse and long- 
continued. Twice she went only two weeks between her periods. 
Once, as they did not return from October to the following July, 
she supposed that they had entirely ceased. 

I have brought this patient before you to illustrate the possible 
relation between a cutaneous eruption and the existence of hys- 
terical symptoms. For twelve years this erup- 
n y S steria! SeaSeand tion has alternated with intractable nervous 
symptoms, more alarming than serious. She 
has been questioned very thorougly, but we cannot learn that she 
ever had any eruption which had been repelled prior to the date 
of her present illness. Nevertheless, the evident relation between 
the disease of the skin and the other symptoms complained of will 
not be doubted. 

Repelled eruptions are, in general, more likely to produce some 
structural disorder of the mucous membranes than to give rise to 
functional or organic lesions of the nervous system. But instances 
are not wanting in which serious neuroses, as, for example, insan- 
ity, epilepsy, paralysis, and neuralgia, have been due to this cause. 



512 THE DISEASES OF WOMEN. 

And so, also, with hysteria. I have seen the most obstinate cases 
refuse to yield to the best affiliated remedies, because they origin- 
ated in the repercussion of some apparently trifling eruption. If 
you will take this clinical hint at its proper value, it may be of 
great service to you bye and bye. These cases are exceptional, it 
is true, but such a one may be the very first on the list of your 
private patients. 

The menstrual irregularity in this case is referable to the critical 
period through which the patient has been passing during the 
last four years. 

Treatment. — We should, so far as is possible, ascertain the 

especial nature of the eruption which has caused, or is so nearly 

related to, the disorder for which we are to 

Character of the erup- „ 

tion may indicate the prescribe. Is it vesicular, papular, pustular 

remedy. ■"■ 

or squamous? Has it always preserved the 
same character? Does it itch, or burn, or what are its peculiar 
sensations? What accidental circumstance is likely to bring it 
out, or aggravate it? These and similar inquiries may influence 
the choice of the remedy, especially in chronic cases. The key to 
the cure may be found through them. 

The increase of duty in the enunctory function of the skin* 
and the increased determination of blood to the cutaneous surface 
at the climacteric, tends to reproduce such latent eruptions and 
humors as may have disappeared and been forgotten during men- 
strual life. It is not an uncommon thing for women to suffer 
from rashes and eruptions instead of the flushes of heat, the per- 
spirations, or the coldness of the surface of which the majority 
of 1 hem complain at what is often called the " dodging-time." If 
these eruptions are generally dislributed they may be critical and 
salutary, in which case they should be treated kindly, and not 
repelled by the use of harsh, or astringent applications; but, if 
they are limited to the external genitals, more especially if they 
persist, and are accompanied by an intractable vaginitis, there is 
reason to fear that they are either of a specific or of a malignant 
character. 

In this case the eruption was originally vesicular. Each time 
it reappears a crop of vesicles forms. They soon break and dis- 
charge, and the serum dries and forms a yellowish crust. This is 
followed by slight itching, especially when the part is exposed to 
the air. 



THE CLIMACTERIC PERIOD. 513 

These symptom indicate rhus tox., and it alone may be suffi- 
cient for the cure, not only of the eruption, but of the incidental 
affection also. I prefer the thirtieth attenuation of this remedy 
for chronic cases. In exceptional cases, it answers very well to 
alternate two potencies of this remedy, as for example, the third 
and the thirtieth. If the rhus fails, we may give sulphur in a 
similar manner. 

Mrs. S. will take a dose of the rhus tox. 30th, every morning 
and night, and report in two weeks. She must be careful to avoid 
pastry, spices, fats and indigestible food of all kinds. And also 
to forbear applying any wash or ointment that might repel this 
eruption and increase the difficulty. 

HYSTERIA. IN A WOMAN AGED SIXTY. 

Case. — I was called, during the night of August 20, 1857, to 

visit Mrs. , aged 60. She was in a semi-conscious state. At 

intervals of from two to five minutes she had spasms which 
affected chiefly the neck and superior extremities. During these 
spasms both the fingers and the wrists were very much flexed. 
The arms and hands trembled constantly. The pulse continued 
quite regular and uniform, both during the paroxysm and in the 
interval. The eyes were slightly suffused, but otherwise natural; 
the pupil being neither dilated nor contracted. When the parox- 
ysm subsided, she became very restless, and moaned and wept 
immoderately. I observed that by directing the conversation to 
other matters, leaving her condition and surroundings for foreign 
topics, the duration of the interval between the fits could be con- 
siderably prolonged. She had been very much exercised and ex- 
cited over the proposed marriage of a daughter, to which she was 
opposed, and for three days had neither slept nor eaten. 

I ordered a cup of strong coffee — for I knew that she could 
not drink this beverage, in health without becoming exceedingly 
nervous and wakeful. Of this she took two teaspoonfuls once in 
ten minutes. She had only a slight spasm after the first dose, and 
in half an hour had fallen quietly asleep. 

The next morning she felt greatly refreshed by her night's rest, 
but was still somewhat weak and exhausted. She had an indis- 
tinct recollection of my having been in her chamber the night pre- 
vious, but knew nothing of having taken the coffee. I ordered tea 
instead of coffee, a generous diet, and for the future less excite- 
ment and fatigue. She recovered promptly without medicine. 

As a rule hysteria occurs only in those women who have not 

33 



514 THE DISEASES OF WOMEN. 

ceased to menstruate. Occasionally, however, we meet with well- 
marked examples thereof before puberty, and 
s tSi s iffe Iaincidenttomen ' after tne climacteric. It is rare to find an 
example of this strange affection in one who is 
more than fifty years of age. I will not detail the clinical history 
of this disease at the present time, but direct your attention to 
one or two points of practical interest in the case before you. 

We make a distinction between spasms and convulsions, which 
it will be well for you to bear in mind. Spasms are not necessa- 
rily, or even generally, accompanied by an entire 

Spasms or convulsions ? p . ,_,.. . . „ . 

loss oi consciousness. I heir manifestation is 
local and temporary. They leave the patient quite decidedly, 
and she becomes almost, if not altogether, rational in the interval. 
Convulsions, on the contrary, are soon, if not from the outset, 
characterized by a complete obliteration or suspension of the per- 
ceptive faculties. The patient knows nothing of what is going 
on around her. She may remain as oblivious during the interval 
as in the paroxysm. Convulsions are accompanied by a more 
general derangement of muscular action. The spasmodic move- 
ments are less apt to be local, and more frequently, implicate the 
different sets of voluntary muscles in succession, beginning with 
those of the head, neck, and superior extremities. 

If you examine the eye of an hysterical subject, you may find 
that it is not changed in its appearance. The pupil is neither 

dilated nor contracted. Sometimes the eye is 

suffused, and the ball may be rolled upwards. 
Now and then there will be a marked difference in the size of the 
pupils, but this may or may not be pathognomonic. I am not aware 
that any author has observed this as a symptom of hysteria, but I 
am inclined to think that it is possessed of some significance as a 
diagnostic sign. 

Add to this that you may sometimes detect the patient looking 
at you askant, or slyly listening to what you say, breathing more 

regularly and freely, or having her spasms at 

The patient's manner. . 

longer intervals, when she discovers that you 
•are quietly busying yourself with other topics of conversation. A 
little tact will sometimes enable you to cut the Gordian knot of 
diagnosis in the most complicated cases of this kind. 

If the pulse is not perturbed, but keeps the even tenor of its 



THE CLIMACTERIC PERIOD. 515 

way, during both the paroxysm and the interval, it is an almost 
positive sign of hysteria. If the attack is refer- 
able to emotional causes, acting upon a too sus- 
ceptible organism, the nervous symptoms that follow will almost 
certainly be tinted with some peculiarities. Loss of sleep is a 
powerful preclisponent of this disease. 

Treatment. — Tact is no less important in the treatment than in 

the differential diagnosis of hysteria. In no other disease is it of 

more practical moment to be personallv ac- 

Valueoftact. . , . , . Tf , , , 

quamted with your patient. It you knoAv her 
peculiarities beforehand, the case may be said to be half cured at 
the outset. There are a thousand little items which the physician 
who is observant gathers up and stores away against a time of 
need. And it often happens that what would appear trivial, turns 
out in the end to be most significant and useful. For, in this 
manner, he may not only interpret the meaning of certain extra- 
ordinary and alarming symptoms, when they are present, but may 
be led at once to the selection of the remedy proper to the case. 

However much we may pride ourselves upon our scientific 
attainments, I assure you that our patients are prone to estimate 
our professional capacity and skill, by our abil- 
so^rceT ° f impromtu re ~ ity to turn all sorts of expedients to the best 
account, at the shortest possible notice. They 
will think more of you, if you can effect a cure with some simple 
and harmless domestic remedy which they have overlooked, like 
the coffee in this case, than if you go through the labor and take 
the time and pains to select the appropriate simillimum. Keep 
your quiver full of arrows, and be ready for any emergency. 

I know of no remedy so well adapted to the relief of nervous 
symptoms, caused by mental fret and friction, and accompanied by 
insomnia, or wakefulness, as coffee. A charac- 
teristic indication for it is found when the 
patient " cannot sleep for thinking." The mind will not rest. 
The mental faculties are more than usually and incessantly active. 
The fact that coffee disagrees with a person when she is well, may 
afford you a clinical hint which will be available in prescribing for 
her when ill. The coffee may be administered in the crude form, 
in the lower, medium, or even the higher potencies, with equally 
good results, as in the case I have cited. In some forms of hys- 



516 1HE DISEASES OF WOMEN. 

terical neuralgia, you may effect a prompt cure with caffeine in 
the third decimal trituration. In one form or another, coffea has 
appeared to me to be very well adapted to many of the nervous 
affections of old people, and of old ladies especially. 

Of late years I have often prescribed caulophyllin for nervous 
conditions that were post-climacteric, with ex- 
cellent results. One of my private patients who 
is an estimable old lady, and who has had a great deal of mental 
care and anxiety on account of her children, suffers from attacks 
that border very closely upon hysteria. They are characterized 
by great nervous tension and unrest, with wakefulness and a 
propensity to work and worry over little things which she would 
not notice at other times. The caulophyllin has such a soothing 
and delightful effect upon her that she calls it my hasheesh, and 
she would not be without it for any consideration. She takes it 
in the third decimal trituration. 

DIABETES AT THE CLIMACTERIC. 

The occurrence of diabetes at the menopause is not infrequent, 
and should be thought of in case of eczema of the vulva and pru- 
ritus. (See pages 512 and 528.) The affection may be chronic, in 
which case it is symptomatic of tuberculosis, or acute and tran- 
sient, as it sometimes is during pregnancy. Its chief constitu- 
tional symptoms are insomnia, flushings that are followed by chills 
and rigors, irritability of temper, hypochondria, anorexia and 
emaciation, with or without a cough. We have elsewhere con- 
sidered this subject very carefully and extensively. ( Clinique Vol. 
V, pages 16 and 148, and Vol. VII, page 181). One of the most 
interesting monographs upon any medical topic that has recently 
appeared is that of Lecorche upon saccharine diabetes in women.* 

*Du Diabete Sucre chez la Femnie par le Doeteur Lecorche, etc., etc., Paris, 1886, pp. 403. 



LECTURE XXXII. 

INCIPIENT PARALYSIS AT THE CLIMACTERIC. 

Incipient paralysis at the climacteric. Post-climacteric neurosis. Climacteric rheuma- 
tism. Bilious colic at the climacteric. Prolapsus uteri, with dropsy, dating from the 
climacteric. Post-climacteric anasarca. 

Case. — Mrs. , aged 48, has had eight children. The last 

two labors were very difficult, from a tall which she received 
during her sixth pregnancy. She now complains of pain "low 
down " on the left side of the spine. This is worse before the flow, 
which is very scanty. She also has some pain, of a pricking char- 
acter and numbness in the right arm, there is vertigo, and she 
cannot sleep after 4 o'clock in the morning. Belladonna 3, four 
times a day. 

April 10. The numbness in the arm, is better, but she com- 
plains of pain in the vertex, and vertigo. Her feet get cold, and 
she has cold creepings followed by hot flashes, sometimes she gets 
blind for a time. She always feels better when lying down, but 
is very apprehensive of danger. Aconite 3. 

April 24. She is very much better; her back does not ache so 
much, the headache and vertigo are better, but the numbness of 
the arm is about the same. The menses have returned, but were 
less free than before. She has a good deal of pain before the flow 
comes on, and after it ceases there is a profuse leucorrhoeal dis- 
charge, which ie acrid and accompanied by bearing-clown pains. 
Sometimes this discharge is thin and watery and lasts about two 
weeks. Kreosotum 3, four times a day. 

May 15. Better in every respect. Same remedy. 

June 5. Is not so well, menses are growing more scanty, and 
the thin excoriating discharge is more profuse, but the headache 
and numbness are relieved. Nitric acid 6. 

June 19. Better in all respects, except the pain in the back. 
Same remedy. 

July 3. The arm and head are very much better, she sleeps well 
now. Same remedy. 

July 17. Her backache is very troublesome, and is worse in 
the left lumbar region. The pain in the head and arm are still 
improving. Merc. sol. 3, four times a day. 

July 31. The pain in the back continues, but she is much 
better in other respects. Merc. sol. 3. 

Aug. 28. She is improving somew hat, but the hand feels numb, 



518 THE DISEASES OF WOMEN. 

and there are darting pains in the arm, and cramps in the right 
limb. Rhus tox., 3. 

Sept. 11. The right arm is well, and the pain has gone to the 
left one which cracks in every joint whenever she moves it. The 
arm and hand burn, there is still pain in the back, and she has 
frightful dreams. Rhus tox., 3, lour times a day. 

Jan. 8. The patient after an absence of several months of com- 
parative freedom from suffering returned, complaining of the old 
pain in her back, arm and shoulder. The menses have been very 
irregular and scant. Bryonia 3. 

March 12. She has pains in her arms and wrists, and hot flushes 
of the face. Bell. 3. 

April 23. The pain now extends the whole length of the right 
arm, which is hot and feels as if it was swollen, and is worse at 
night. She has chills, followed by headache and if she stands long 
her feet swell. She has an eruption at times on the lower limbs. 
Apis 3, three times a day. 

May 28. Her arm is still painful, and is Averse on lying down, 
and at night. She still has some pain in her head, with attacks of 
vertigo. At times she is cold all over and is only relieved by being 
rubbed. Merc. sol. 6, four times a day. 

June 4. She is much better. Continue same remedy. 

Sept. 24. Her chief complaint is of a pain in her right shoulder, 
which becomes cold and is worse at night, so that she cannot sleep, 
and she is unable to use it. The eruption still annoys her, and is 
now on the arms also. Nux 3, three times a day. 

[She continued to report from time to time, and with the final 
cessation of the menses the symptoms of incipient paralysis dis- 
appeared. The eruption, however, lingered for some weeks, being- 
limited exclusively to the extremities, both upper and lower. 
The cold creepings and the hot flashes disappeared when the erup- 
tion came, and did not return. The best remedy was sulphur 30.] 

You are not to suppose that the diseases of the climacteric 
include those affections only which follow the final arrest of the 

menses. For it may happen that they shall 
pr C ec^h?aTres S . may anticipate that period, just as a child may be ill 

from teething &ome weeks or even some months 
before the teeth can be seen. This crisis often forecasts itself in 
the diseases to which most women are subject, at and after the age 
of forty; and there are certain classes of patients in whom you 
will find that this influence is quite peculiar. Most women who 
are of a plethoric habit, and especially those who have grown 



PARALYSIS AT THE CLIMACT. RIC. 519 

stout and fleshy as they have grown older, find themselves men- 
struating more scantily, and little by little the flow ceases until 
it finally stops. In proportion as it diminishes a sei ies of nervous 
derangements are developed, which depend upon a congestion of 
the cerebro-spinal centres, and apoplectic and paralytic symptoms 
creep on insidiously. 

Under these circumstances it may be of the utmost importance 

to recognize the significance of these symptoms, and to be able to 

tide the patient over her difficulty. If we can 

Prophylaxis of the gMeld h f i mpe nding paralysis, and 

menopause. L a i J » 

keep her from being a physical wreck for the 
balance of her life, we shall have done a good deed, and one that 
will bring a grateful after-glow to our own experience. 

There is nothing very striking in the recital of this poor woman's 
case, or in the choice of remedies for its cure, but the result was 

all that could have been desired. It serves to 

illustrate the fact that in our practical lives as 
gynaecologists we must not always expect very prompt and im- 
mediate results from our treatment. For where a slowly coming 
crisis like the climacteric is concerned, we may need to persevere 
for many months before our object is finally accomplished. 

I ought to tell you that it is not an infrequent occurrence for 
the uterine discharges to become thin, watery, and more or less 

acrid and excoriating as the change of life 

ch^elrtre^nge^ 8 " a PP roacnes ' ancl tnat > therefore, you are not to 
conclude that such a patient is certain to fall a 
victim to one of the forms of uterine cancer. This kind of a dis- 
charge, in this class of cases, is self-limited and not malieriant. 
But bearing in mind that cancer of the womb is more frequent 
after the climacteric, you should be careful in promising an exemp- 
tion from that terrible disease while the discharge continues to be 
corrosive in character. 

It is for the relief of this kind of a discharge, in connection with 
the menses at the menopause, that I prefer the use of nitric acid, 
and sometimes of kreosotum, either of which 
acrid flow. ° r * may be given in the third or the sixth dilution. 
When the menses are scanty with flushings of 
the face and vertigo, sanguinaria 3, is often an excellent remedy. 
For the throbbing pulsations, and local determinations of blood 



520 THE DISEASES OF WOMEN. 

to the head and to the spine, which threaten to end in paralysis, 
glonoine is a better remedy than lachesis. 

POST-CLIMACTEEIC NEUROSIS. 

Case. — Mrs. , German, aged sixty, midwife, has been an 

invalid tor eight years past. Her menses ceased without any other 
ill effect than that, when they stopped, she became subject to dis- 
tention of the stomach and abdomen, with shooting, stabbing 
pains that came mostly at night and forced her to cry so loud 
that her neighbors could hear her. The seat of these pains, here 
and there over the abdomen, sometimes became swollen and tender 
to the touch. For months at a time she has not been entirely free 
from this local hyperesthesia. The bloating of the stomach is 
sometimes accompanied by a burning pain at the epigastrium. 

This patient has been prescribed for by many physicians, but 
without relief. Last year she made a voyage to Germany ex- 
pressly to consult certain eminent practitioners, but derived no 
benefit from their prescriptions. Through the advice of a neigh- 
bor, she came here three weeks ago, and I recognized the relation 
existing between her symptoms and the menopause. For it may 
happen that the remote consequences of this important " change" 
shall be entailed upon a woman for many years after the flow 
has ceased. My first prescription was the citrate of iron and 
strychnia in the 3d decimal trituration; but it did her no good. 
At the next visit she took atropine in the same potency, to be 
repeated every three hours. You have heard her story and can 
believe her when she says that for eight years she has not been so 
free from suffering as since she has taken that remedy. We will 
continue it, but repeat it only thrice daily. 

CLIMACTERIC RHEUMATISM. 

Case. — This patient is forty-five years old, married, and has had 
several children. She now complains of pains in her shoulders 
and chest, which she thinks were caused by taking cold about a year 
ago. At that time, an abscess formed in her left breast, which 
was lanced and discharged freely. She was not nursing at the 
time. Her menstruation was established at eighteen, and still 
continues. For six months previous to the flow, she had been 
afflicted with blindness, which came in paroxysms in the afternoon, 
and continued until the next morning. The flow now lasts a 
week, and is copious, causing great exhaustion. There is a cold 



BILIOUS COLIC AT THE CLIMACTERIC. 521 

sensation extending from the knees down to the feet, which are 
always cold. Silicea 3, four times a day. 

May 12. Is feeling' much better; has some pains across her 
shoulders, but is gaining strength. Silicea 3. 

May 19. The patient was improving until, beinsc unfortunately 
exposed to the rain, she took a severe cold, and the old pains in 
the neck and shoulders have returned. The menses are also 
delayed. Rhus tox. 3.* 

June 2. The pain in the shoulders has disappeared, but there 
is still some in the region of the stomach and liver, which she 
thinks is aggravated upon taking a deep inspiration. The menses 
have not yet appeared. Rhus tox. 3. 

[The record shows that this patient afterward suffered from 
muscular rheumatism in other parts of the body, but chiefly in the 
fleshy parts of the arms, for which she took macrotin with the best 
effect. The menses came less frequently, and finally ceased alto- 
gether, after which the rheumatism soon disappeared.] 

Rheumatism at the climacteric is quite as much of an outlaw as 
it is under other and very different conditions. This case was 
cured by macrotin 3, under indications which 
have come to be regarded as reliable. A little 
while ago, you remember, we cured another case with nux vomica 
3, when, along with the rheumatic pain in the right arm, there 
was formication, or a feeling as if ants were crawling beneath the 
skin. Other cases have been cured with gelsemium, cactus, 
lachesis, aconite, and sanguinaria. 

BILIOUS COLIC AT THE CLIMACTERIC. 

Case. — Mrs. T. aged 52, ceased to menstruate four years ago. 
For two years before the change came she had been subject to 
what her physician said Avere attacks of bilious colic that were due 
to the passage of gall-stones. After the flow stopped these attacks 
of the colic became less severe, but they still continued to recur 
at intervals of from three to ten days, when she applied to this 
clinic six weeks ago. She has been forced to be very careful in 
her diet, and has observed that when the lit ccmes on, if she lies 
down and keeps very quiet it is less severe and passes oft* more 
quickly. She says that her mother died of cancer of the stomach. 

Concerning the cause of the difficulty she is firmly persuaded 
that it was due to fright. The circumstances were that, while she 
was menstruating, word was brought to her that her child was 
dead. He Avas soon brought home from school in a horrible fit, 
after Avhich he was ill for a long time and she nursed him. When 
this happened she had already had some wa ruing of the approach 



522 THE DISEASES OF WOMEN. 

of the climacteric ; and after this fright and worry she not only 
had the attacks of colic, but she became very irregular and suffered 
more than usual at the month. 

For the first fortnight she took china 3, three times daily, with 
the effect to lessen the severity of the paroxysms, but they still 
continued to return as before. She was then put upon chamomilla 
3, and improved in every way. In a little while she observed 
that a single dose of this remedy would snuff out a paroxysm, and 
soon they ceased coming altogether. 

If the change of life always came at a certain age, and if its 
advent could influence the health of women for a certain period 

only, before its arrival, we should be better able 
cifmrcterif 0118 ^ 1116 t0 estimate its effects in a clinical way, and 

also to prescribe for them intelligently. But 
when a woman has been out of health for two years in anticipation 
of this epoch, and when during that period she has been exposed to 
an exciting cause that would certainly have made her ill at any 
other time, the morbid conditions are so complicated that it is very 
difficult to solve them. If we add to this, as in the case under 
review, a manifest predisposition to a disease, or a dyscrasia like 
that of cancer, we shall be very chary of promising to cure the 
patient, or even to make her comfortable for any considerable 
length of time. 

You have witnessed the remarkable effect of chamomilla in this 

case, and the delight with which our patient 

A qualified prognosis. c 

ascribed the result to the remedy; but I must 
warn you not to conclude that her disease is radically cured. 

PROLAPSUS UTERI WITH DROPSY, DATING FROM THE CLIMACTERIC 

PERIOD. 

Case. — Mrs. , aged 52, has had four children, the youngest 

of which is now fifteen years old. She has had but one abortion, 
and that occurred prior to the birth of her last child. Her men- 
struation was first established at the age of twelve years, and it 
ceased at forty, that is to say twelve years ago. She says that 
her mother met with her " change " at the same age. The first 
symptom of ill health that this woman remarked in her own case, 
was a bloated feeling in the abdomen, which was sometimes quite 
full and distended, and again would subside to almost its natural 
size. This enlargement, she says, was uniform in its development,, 
and not limited to any particular portion of the abdomen. There 
has been no tenderness on pressure, and no soreness. The swell- 



PROLAPSUS AT HIE CLIMACTERIC. 52S 

ing is notably increased by exercise, and is accompanied by bloat- 
ing and pufnness of the limbs, the feet, and the face. 

The bowels are habitually constipated, and if she fails to take a 
laxative pill, she has a great deal of straining at stool, and finally 
passes only dry, hard scybala. By reason of this urging at stool, 
she is quite positive that the womb is sometimes very much pro- 
lapsed, so much so, indeed, as to threaten protrusion from the 
vulva. She is also certain that at these times she has felt it 
lying between the labia majora. When she lies with the head low 
and the hips raised, the " tumor" disappears. The Dispensary 
Physician, has made a careful vaginal examination of this case, and 
diagnosticates it as one of confirmed prolapsus uteri. The swell- 
ing of the integument is evidently dropsical, as is proved by its 
" pitting" under the pressure of my finger. The urine is scanty 
and high colored ; the appetite capricious. 

Uterine displacements are so frequently related, either directly 

or indirectly, to abortion and to labor at term, that it will be well 

Parturition a cause of for you, in every case, to inquire whether the 

uterine deviations, and atient has rece ntlv passed through the process 

the climacteric period -»■ - • *■ o i 

predisposes thereto. of parturition. This woman's last labor occurred 
fifteen years ago, and the probability that the uterine deviation 
dates from that event is very much lessened by the fact that it was 
not noticed until three years later. The prolapsus came on with 
the "change," or the advent of the grand climacteric, which, in 
her case, occurred at the early age of forty years. It is, therefore, 
possible for the uterus to become displaced at the end of the child- 
bearing period, and from other causes than a defect in its proper 
involution, or folding upon itself, after labor. 

Now the most obvious reason why she, at her time of life, has a 

prolapsus so decided, and which is only remotely, if at all, related 

Dropsy at the ciimac- to pregnancy, is the co-existence of dropsy, to 

teric, and constipation, which many women are liable at the climacteric. 

causes of prolapsus. The .^^ ftnd general anasarca are indicative 

of a weakened and relaxed fibre, which strongly predisposes to 
uterine displacements. Add to this the direct pressure imposed 
upon the womb, also the semi-paralyzed condition of the rectum, 
and of the perineum (which has lost its resiliency), and the dis- 
placement downwards, even to the extent of procidentia, is readily 
explained. The only support that the uterus has from below, is 
from the contractile wall of the vagina, which rests like a column 
upon the perineum ; and the chief muscles of the latter are con- 



524 THE DISEASES OF WOMEN. 

nected with the rectum and the anus. In the constipation which 
is incident to chronic cases of this kind, the tone and elasticity of 
these tissues is partially or wholly lost. The straining at stool 
may therefore not only serve to perpetuate the luxation, but also 
to change its degree, and even its variety. It may convert a case 
of retroflexion into one of retroversion, or of .simple prolapsus 
into procidentia. This relaxed or weakened condition of the 
muscular floor of the pelvis is, as I have already said, much more 
likely to follow upon the heels of labor, either premature or at 
term; but it also occurs in those who, like this patient, have 
borne numerous children, and Avho become subsequently afflicted 
with protracted and debilitating disease. 

Treatment. — The relief afforded by the horizontal position, with 

the hips elevated, is significant. Many cases of prolapsus need but 

little beside appropriate postural treatment. It 

Postural treatment, fe } ng that th displaced uterilS Will 

and the perineal pad. *■ l l 

gravitate into its proper position, if the patient 
can keep off her feet. But it is not always possible, nor would it 
be best, for women with this infirmity to go to bed and remain 
there. Those of the poorer classes must work, and they ail need 
exercise. And thus it may become necessary to supply a means 
of support which shall supplement the relaxed muscular fibre of 
the vagina and of the perineum. It is in just such examples of 
prolapsus as this, occurring in women somewhat advanced in life, 
who are ill in other respects, and constitutionally weak, and withal 
obliged to walk and to work daily, that I am accustomed to recom- 
mend the wearing of the perineal pad, as a means of temporary 
relief. It will accomplish more, and is more available in most 
instances, than any other form of supporter. In conjunction with 
the proper internal remedies, its effect is to tone up the parts 
which afford the natural support for the uterus, and at the same 
time to allow the patient to move about with impunity. I shall 
speak, in a subsequent lecture, of the proper indications for pes- 
saries, and the value of them in this and other forms of uterine 
displacement, as they occur under different circumstances. 

It is important that this patient should re- 
an^ y r?mea 3 ieT CaUti0nS ' f rani fr° m a U violent exercise, more especially 

from lilting heavy weights, and from scrub- 
bing, sweeping and ironing. She should not permit herself to 



POST-CLIMACTERIC ANASARCA. 525 

strain at stool, neither sit in a constrained position for any con- 
siderable time. Her food should consist largely of albuminous 
matters, designed to improve the quality of the blood; and of 
vegetable substances, particularly of such as are somewhat laxa- 
tive, as fruits, and bread made of unbolted flour. 

The remedies that are most prominently indicated for this 

particular case are mix vomica and apis mellifica. And, since 

neither of them will cover the two sets of syrup. 

Internal remedies. . 

toms which are present, 1 recommend them to 
be given in alternation, the former at evening, and the latter in 
the morning and at noon of each day. The mix vomica is espe- 
cially indicated on account of the constipation, the straining at 
stool, the passage of scybala, and the threatened escape of the 
uterus from the pelvic cavity. There are the best possible patho- 
gentic and physiological reasons for its employment, although in 
chronic cases like this, I think it should not be given more than 
cnce or twice daily, hi similar cases, lycopodium, or sepia, will 
sometimes prove of the greatest utility. 

The manifest relation between the commencement of the drop- 
sical symptoms, and the arrest or cessation of the menstrual 
function furnishes us with a characteristic indication for the apis 
mellifica. In using this remedy, my own preference is for the 
second or third decimal triturations. 

POST-CLIMACTERIC . ANASARCA. 

Cose. — Mrs. , is 66 years old. She is married, has borne 

sixteen living children, and has had two miscarriages. Ten of the 
sixteen children died before they were one year old. She has 
been constantly ill for six or seven years. The menses apparently 
ceased at the age of fifty-two, but were intermittent and irreg- 
ular during the three following years. She had always flowed 
copiously at the month, and suffered much from exhaustion. 
There is now a general anasarca. The urine is scant; there is 
pain in the kidneys, and her limbs " burn like fire." There 
are also varicose veins of the lower extremities. She has some 
vertigo, but the appetite and the sleep are good. Hamamelis 3. 

May 26. She thinks there is some improvement, but the urine 
is still scant; her limbs burn, and the veins are still swollen. 
Hamamelis 3. 

June 2. She is feeling very much better; her limbs are less 
troublesome ; the quantity of urine has increased, and with that all 



52G THE DISEASES OF WOMEN. 

the symptoms are improved. Continue the hamamelis 3, three 
times a day. 

The two prominent factors in this case were such as often co- 
exist, viz. (1) a tardy venous circulation, and (2) anaemia. 
m . . . . Both these conditions are incident to the haemor- 

The haemorrha<nc 

diathesis at the rhagic diathesis. We know that this patient 
menopause. wag ft n8emorr h a oric subject because she flowed 

so freely at the month, and because she was the victim not onlyol 
varicose veins, but of dropsy from a sluggishness of the general 
circulation. I have often verified the indications for hamamelis in 
cases like this, and I urge you not to forget that, although it is 
not classed among the remedies which are especially suited to the 
climacteric, it is nevertheless, of great service under these peculiar 
conditions. 

I cannot refrain from expressing the opinion that the slight 
tenure of life of ten of this poor woman's children, who died before 
they were a year old, was chargable to the impoverished condition 
of her blood, made worse by pregnancy and lactation, just as it has 
been by the climacteric. 



Part Eighth. 



DISEASES THAT MAY OCCUR IN MORE THAN ONE 

OF THE CRITICAL PERIODS TO WHICH 

WOMEN ARE SUBJECT. 



LECTURE XXXIII. 

AFFECTIONS OF THE EXTERNAL GENERATIVE ORGANS. 

Pruritus of the vulva. Abscess of the labia and of the vulvo-vaginal gland. Vulvo- 
vaginitis. Prurigenous vulvitis. Infantile leucorrhcea. 

Although, as we have seen, some of the diseases of women are 
limited to a single crisis, in which case we can classify and 
study them separately, yet very often two or more of these periods 
may merge and be involved in their clinical history. The etiology 
of this class of cases is therefore complicated, and their special 
pathology and treatment difficult. Some of them date from 
puberty, but all of them are more or less intimately related to the 
allied functions of menstruation and reproduction. 

The diseases which naturally come under this section of our 
subject are those which affect the external and internal generative 
organs, the bladder, and the rectum. They are chiefly local in 
character, and have this peculiarity in common, that, while they 
may occur in either or all of the periods of which we have spoken, 
their treatment is partly medical and partly surgical. This gives 
a remarkable interest to their clinical study, for physicians are not 
agreed upon the relative merits of these two methods of treat- 
ment; nor are we always prepared to say where one should end 
and the other should begin, where one is better than the other, 
or where they should be used conjointly. 

527 



528 THE DISEASES OF WOMEN, 



PRURITUS OF THE VULVA. 

Case. — Mrs. , a healthy looking woman, has an infant of 

three months, which is her third child. She says that when the 
babe was a month old she began to suffer from an itching of the 
external genitals. At times this itching is almost insupportable, 
and she really feels as if she might become insane in consequence 
of it. She describes it as worse at evening, after being much up- 
on her feet during the day. There is a mucous secretion from 
the vagina which is sometimes quite copious, but generally scanty, 
and which she has observed is very apt to dry upon the parts 
exposed to the air, where it forms into scales that are easily de- 
tached by rubbing. Urination is sometimes followed by scalding 
and burning sensations, which are referred to the vulva rather 
than to the urethra. Coitus is painful, and apt to be succeeded 
by a pinkish discharge from the vulvo-vaginal canal. She had 
this local trouble while nursing both her former children, with 
the last of which it continued for more than a year. Her skin is 
fair, and to her knowledge she has never had any eruption. The 
babe is well, and thrives upon the breast exclusively. 

This form of prurigo usually depends upon inflammation of 
some portion of the mucous membrane lining the vulva. It is in- 
cident both to the purulent and the follicular 

Various causes. t • • • • • 

forms oi vulvitis, 01 which pruritus is the most 
distressing symptom. Among the causes which may induce it 
are, a lack of cleanliness ; the contact of acrid vaginal secretions, 
as in leucorrhoea, uterine cancer, etc. ; masturbation ; gonorrhoea ; 
syphilis ; vegetative growths ; ascarides ; indigestion ; diabetes ; 
and the use of alcoholic drinks or highly seasoned food. Some- 
times it is caused by acrid vaginal discharges poured out during 
pregnancy, and may result in abortion. Again, it is developed 
during lactation, and will not cease entirely until the child is 
weaned. In little girls it may accompany the exanthemata, and 
disappear with them. In women, it sometimes alternates with a 
chronic eruption to which they have been subject. In very nerv- 
ous persons, it may possibly arise from simple hyperesthesia of 
the mucous membrane. There may be aphthous ulceration, or 
perhaps an herpetic or eczematous eruption, or an abrasion at the 
junction of the mucous membrane with the skin, which shall be 
sufficient to account for the suffering. Not unfrequently the sur- 



PRUEIIUS OF THE VULVA. 529 

face is so heated and inflamed that the mucus secreted is dried 
upon the parts, and this causes such intolerable itching that, no 
matter where she is, or what her surroundings, the patient can- 
not refrain from rubbing or scratching. Another cause of this 
troublesome affection in certain cases is disease of the uterine cer- 
vix. Some attacks of pruritus pudendi have been attributed to a 
varicose condition of the veins of the vagina. Others are known 
to arise from the presence either of a peculiar parasite (pediculus 
pubis), or of the itch insect (acarus scabiei), in the hairy portion 
of the mons veneris. 

Dr. Meigs reports the following case :* 

" I was consulted for a young lady about twenty years of age, 
who suffered from an intolerable pruritus and uneasiness of the 

vulva. Her physician had prescribed many and 
^Pruritus from trichiasis. yar i ous remedies in vain. He had examined, 

by inspection, the privities, but could not dis- 
cover the cause ; which, however, was not dissipated by his appli- 
cation of nitrate of silver and other medicines. When I was 
called to give my opinion of the case, I was much surprised to find 
it attributable to a real trichiasis of the vulva. The hairs that 
grow usually on the derma, and then not very close to the epithe- 
lial surface, had sprung from the very margin of the mucous mem- 
brane of each labium. They were straight, like eyelashes, and 
pointed inwards. It was from the tickling and pricking of the 
points of these hairs that her distress arose. They were all re- 
moved by her nurse, with tweezers, and the complaint disap- 
peared." 

The itching, burning or stinging sensation, whichever it may 
be, is not always constant, but remits and intermits. It may be 

aggravated by exercise, fatigue, excessive heat 

of the weather, standing before a fire, by the 
warmth of the bed, by mental emotion, passional excitement, or 
urination. It may be worse at evening and at night, thus pre- 
venting rest and sleep. Sometimes the patient is compelled to 
leave her bed and walk about the room in order to obtain 
the least respite from her suffering. It worries her into a nervous 
state, rendering her unhappy, petulant and ill. The paroxysms 
may be so severe as almost to drive her crazy. Sometimes. 

* Woman : her Diseases and Remedies, etc. Phila., 1859 ! P- 9&- 



530 THE DISEASES OF WOMEN. 

they give rise to local spasm in the form of vaginismus, or in a 
more general way to an hysterical fit. In the mildest variety the 
cutaneous surface of the larger labia is the seat of formication, or 
crawling sensations, which torture the patient exceedingly. In 
this case she will insist that multitudes of little insects are run- 
ning over the external generative organs. When the mucous 
membrane reflected over the clitoris is the seat of the itching, 
the case develops into one of nymphomania. 

The scratching and rubbing of the parts really affords but little 
permanent relief, and yet it is impossible for the poor victim to 
resist such a propensity. In this manner the 
wound's 115 from self " inflicted surface is sometimes so severely wounded that 
extensive injury is done to the soft tissues. In 
case there is an eruption, the vesiculse are broken and the nails 
may cause extensive abrasions and ulceration. Sometimes the sen- 
sation of heat in the parts affected is even worse than the itching. 
In some women the attack precedes the menstrual flow. The 
physiological determination of blood to the pelvic viscera, and 
the irritable condition of the vulvo-vaginal 
str^i y P P eriod de the men " glands and nerves, which usher in the "pe- 
riod," seem sufficient to account for this result. 
These persons become exceedingly nervous, and suffer greatly at 
such times. They are on the eve of an hysterical paroxysm, it 
may be for hours together ; fitful, capricious, disheartened, and 
sometimes almost demoralized. When the flow commences the 
crisis is soon past, and the pruritus may not return during the 
month. In such cases the proper menstrual flow is often supple- 
mented by a copious leucorrhoeal discharge. The most intract- 
able examples of neuralgic and spasmodic 
Pruritus with dysmenor- dvsmenorrho3a mav originate in this form of 

rhoea and amenorrhoea. J jo 

pruritus. Sometimes the pruritus comes on for 
a few nights after the cessation of the flow at each period. Or 
it may be due to menstrual suppression, constituting the prurigo 
latens of Alibert. The liability to this painful 
Pruritus at the dimac- disorder appears to increase with advancing 
age. Not unfrequently it occurs at the climac- 
teric. A considerable proportion of women suffer more or less 
from it about the time the menses cease. 

This itching of the genitals is also one of the contingents of 



PEUEITUS OF THE VULVA. 531 

pregnancy. It is more apt to come on after than before the third 

month, and may either cause abortion, or con- 

Pruritus during preg- tinue to term. Some women always have it 

nancy. J 

when they are pregnant. Here is a striking 
instance of general and local pruritus in a pregnant woman, pub- 
lished by M. Maslieurat-Lagemarcl.* 

" Mrs. , aged 32, first became pregnant when twenty-one 

years old. Prior to the sixth month she suffered but little from 

the disorders incident to gestation ; but after 

Case. . to 

that time, and without any apparent cause, she 
was attacked with intense pruritus, which extended over the 
whole body. The legs, thighs and genitals were first seized, but 
at the eighth month the itching extended even to the palms of 
the hands and the soles of the feet. The rubbing and scratching, 
which she could not resist or avoid, caused premature labor, im- 
mediately following which the irritation ceased. She became 
pregnant again, and, as before, continued well until the sixth 
month. Then the pruritus returned, and continued until the 
seventh month, when she miscarried. This experience was re- 
peated six times in succession ; so that in all she had eight pre- 
mature labors which were due to excessive pruritus." 

Diseases about and within the uterine cervix are sometimes 
accompanied by an inveterate pruritus, which may exist for years, 

and defy all ordinary modes of treatment. It 
dis C ea^ licated wIth uterine mav b e due to simple induration, or ulceration 

of the cervix, endo-metritis, hydatids, polypi, 
or fibroids. A very painful form of it may arise from inoculation 
and irritation caused by contact of matters with cauliflower ex- 
crescence ; and some authors believe that pruritus of the vulva is, 
under peculiar circumstances, a suspicious sign of uterine cancer 
in its earliest stages. (?) In other cases, uterine disease is caused 
by an extension of the inflammation, which is attendant upon the 
pruritus, from the vulva to the uterine cavity. 

As in this case, this troublesome affection may torment the 

woman only during the nursing period. Under 
iaSon d to the perIod ° f these circumstances, weaning will generally 

cure it with as much certainty and promptness 
as did the emptying of the womb in the example just quoted. 

* Gazette Medicale, 15 Mars, 1848, p. 204. 



532 THE DISEASES OF WOMEN. 

The danger from pruritus of the vulva is that it may persist 
until it has so exhausted the nervous energies as to leave the sys- 
tem an easy prey to organic disease. Inveterate cases are likely 
to be accompanied by digestive disorders of the 

Prognosis. . L J ° . . 

most serious nature. lne prognosis will there- 
fore vary with the clinical history, the cause, the complications, 
and the duration of the disease, as well as with the temperament, 
time of life, dyscrasia, and the original strength and vigor of the 
patient. 

Treatment. — This is local and general. It would be cruel to 
deny our patient the use of such palliatives as will mitigate her 
sufferings without in the least interfering with the cure of her 
complaint. And, since the local expedients to which you will be 
obliged to resort must vary in different cases, you should possess 
an ample stock of them in the outset. 

First of all is cleanliness, which can be secured by having the 

parts frequently bathed with suds from castile soap. The honey 

and juniper tar soaps answer equally well. 

Topical palliatives. . 1 _ 

rledgets 01 old, solt linen may be wet either 
with cold or warm water, as the patient prefers, and applied fre- 
quently. Or wheat-bran water may be used in the same way,, 
and, in some cases, injected per vaginum. If there is a vesicular 
eruption, with a raw surface, or the burning in the urethra and 
dysuria are very marked, water, or glycerine, or both, may be 
medicated with the tincture of cantharis, and applied to the vulva 
by means of compresses. The urtica urens is appropriate to the 
erythematous form, with a scarlet surface of the mucous mem- 
brane, and where there is complaint of burning and stinging as 
from nettles. 

In case of aphthous ulceration, you should not forget the com- 
mon borax, and the hydrastis, both of which are in excellent re- 
pute as palliatives in this form of pruritus. An emulsion of olive 
oil and lime water is sometimes of excellent service. Or a roll 
of lint dipped in almond oil may be introduced into the vagina. 
Oolombat recommends a lotion composed of a tablespoonful of 
cologne water to a teacupful of warm water. Lisfranc prefers a 
mixture of starch five parts, and camphor one part, to be applied 
once daily to the inflamed surface, the latter having been washed 
before the preparation is used. Scanzoni extols a liniment com- 



PRURITUS OF THE VULVA. 533 

posed of chloroform two parts and almond oil thirty parts. Hewitt 
prefers them in the proportion of one part of the former to six of 
the latter. In extreme cases, others prescribe a mixture of melted 
lard and chloroform. Or the rhigolene, ether, or chloroform spray 
may be used exceptionally. 

If there is considerable local inflammation, I am in the habit of 

prescribing a poultice of ground slippery elm, or of linseed meal. 

If the case is chronic, and very obstinate, more 

othe°r r w V ise vitis,syphilitic ° r es P ec i a % if ^ * s syphilitic, the surface may be 
painted over with a solution of the nitrate of 
silver, composed of one grain to the ounce of distilled water. In 
other inveterate examples the chromic and hydrocyanic acids are 
permissible and useful. 

If the itching is due to the presence of pediculi, a mixture con- 
sisting of the ointment of the yellow nitrate of mercury one part, 
and lard three parts, may be smeared over the 

For pediculi. ascarides, etc. .. . _ _ 

pudenda. Or an infusion of tobacco may be 
applied locally with a view to disgust and destroy the parasite. 
In trichiasis of the vulva you may follow the treatment prescribed 
by Dr. Meigs, as quoted above. If the irritation is due to the 
presence of ascarides in the rectum or vagina, or both, injections 
of common salt and water, olive oil, or of a decoction of garlic, 
may be ordered. 

It is very important to enjoin quiet. The fresh air is, however, 
requisite. Sexual intercourse should p'enerallv, 

Rest, diet, etc. X . . ' ' . . f J 

but not invariably, be forbidden. A proper, 
unstimulating diet should be chosen, and every form of alcoholic 
•drink denied. 

I will not detain you with detailed indications for remedies that 
may require to be given internally. Let it suffice that the utmosl 

importance must attach to the special cause and 

Internal remedies. ,.-,.., 

history of each individual case in which you 
are consulted. For there is no single specific for this affection, 
any more than there is for hysteria. Natrum muriaticum, sepia, 
silicea, sulphur, arsenicum, calcarea carb., conium, mercurius, and 
the various acids, are most frequently given. 

Dr. Wm. Hunter found that the introduction of the female 
catheter would sometimes afford immediate and complete relief. 



534 THE DISEASES OF AVOMEN. 

Others have recommended the application of a water-proof cloth 
made of rubber, or gold-beaters' skin. The lo- 

Other expedients. _ 

cal use ot the essence ot peppermint will answer 
in some cases. 

The use of agaricus muscarius has been advised ; and my friend 
Dr. D. S. Smith of this city, and also Jousset and Baehr praise 
the tincture of conium in a low dilution for 
internal and external use. Dr. W. H. Holcombe, 
of New Orleans, writes:* "When sympathetic with ovarian or 
uterine trouble, platina 6, internally, and caladium seguinum 
externally have rarely failed me. When vesicles or excoriations 
accompany the itching, graphites, internally and externally, is 
truly specific, but I give it low — the first decimal trituration for 
the wash, and the third decimal three times a day by the mouth. 
For the pruritus ot young girls, with leucorrhcea, and associated 
with ascarius vermicularis, nightly injections ot a strong decoction 
ot garlic with an internal close of ignatia are promptly curative.'* 
In his Horn. Therapie., Vol. II, Kafka advises: " for itching of 
the external labia, mercurius 3, or kreosotum 3 ; for itching of the 
mons veneris, natrum muriaticum 6, or 30, or carbo vegetabilis 
6 ; for itching of the vagina, if the sexual instinct is not increased, 
sulphur 30, graphites 6 or 30, natrum mur. 6-30, belladonna 6; 
ditto Avith erotismus and nisus sexualis excedens, nux vomica 6, 
cannabis indicus 3, calcarea carb. 6, zincum metallicum 6; with 
nymphomania, bartya carb. 6, mix vomica 3-6, ignacia 3-6, plating 
6, zincum metal. 6. In all cases of pruritus pudenda lukewarm 
sitz-baths and full baths are to be recommended." 

ABSCESS OF THE LABIA MAJORA AND OF THE VULVO- VAGINAL GLAND. 

An abscess of the labia is the result of an inflammation of its 
cellular tissue, or of the vulvo-vaginal (Bartholin's) gland. For 

some unaccountable reason it is more frequent. 

on the left than on the right side. When the 
first symptom observed is a hard tumor in the centre of the labium , 
without any superficial inflammation, the affection is glandular, 
and may be gonorrhceal or not. When the inflammation is 
specific, it has travelled along the duct before invading the gland ; 
but the non-specific form may arise from simple obstruction of the 

*The U. S. Medical and Surgical Journal, Vol. 8, p. 49. 



ABSCESSS OF THE LABIA, ETC. 535 

duct. In both cases the abscess will discharge a very nauseous 
and offensive matter. 

This form of abscess is most frequent between seventeen and 

thirty years of age. It is caused, in most cases, by traumatism of 

the genitals as in rape, and excessive coitus, 

and also by gonorrhoea! vulvitis and vaginitis. 

Martineau reports the following cases: * 

^ The first was that of a young woman of 22, who, meeting her 
lover, from whom she had been separated during the siege of Paris 
during the commune in 1870-71, submitted to 
his embraces nine times in one night. There 
followed from it an abscess of the left vulvo-vaginal gland, for 
which she sought my advice. The cure was completed at the 
end of eight days. 

" The second case was that of a young woman of 25 who lived 
with her parents and only saw her lover evenings. One evening 
between the hours of 8 and 11 coitus was re- 
peated seven times. Two days after there was 
a slight itching of the labium majus, then smarting and swelling*; 
the patient entered the hospital and I found an abscess of the left 
vulva-vaginal gland, which healed at the end of eight days. 

" These are not isolated cases. The gynaecologists mention sev- 
eral and I doubt not physicians have occasion to see them in their 
practice, especially in young brides, where to excessive coitus 
must be added, difficulty of defloration and the fatigue of the bridal 
trip. Tardieu observed a case as the result of a rape; he cites a 
case in a girl of sixteen who was obliged to submit to the repeated 
assults of her ravisher at least twenty times in less than eight 
days." 

It is sometimes connected with tardy menstruation. One of 
my patients has had twelve of these abscesses which in every 
instance has been connected with the menstrual period. More 
rarely it occurs during pregnancy, or as a result of the traumatism 
of the soft parts during labor. 

The symptoms are pain in walking or sitting', a mild puritus 

and unusual moisture of the parts, swelling of 

the affected side, the formation of a small hot 

tumor, which is pear-shaped and which closes the vulvar orifice. 

*La France Medicale, July 21, 1880. 



536 



THE DISEASES OF WOMEN. 




The mucous membrane covering the vaginal side of the tumor is 
congested and purplish, and the tumor soon becomes fluctuating-. 
In from four to eight or ten days the abscess breaks and discharges 
its contents, but only perhaps to refill at the next monthly period, 
or to develop a fistula which may continue to discharge. 

Martineau in his clinical lecture says : 

" The diagnosis is generally easy. This pyriform tumor, situ- 
ated at the entrance of the vulvar 
ring, between the labium majus, 
which it pushes 

Diagnosis. 

outward, and the 
labium minus, which it flattens with- 
in, clearly detached from the neigh- 
boring parts and leaving intact the 
superior segment of the vulva, can- 
not be confounded with a stercoral 
abscess, with a presecto-vulvar ab- 
scess, nor with a purulent collection, 
proceeding from caries of the isch- 

. Fig. 46. Abscess of the labia 

ium. One will not confound this maj-ira. 

abscess with abscess of the labium majus. In fact, phlegmon of 

the greater lip is seated at the external portion of the vulva ; it 

projects outward, not inward, 
like abscess of the vulvo-vaginal 
gland; finally, while the latter is 
habitually circumscribed and uni- 
lateral, phlegmon often becomes 
general, extending to the labia 
minora, the clitoris, and even ac- 
cording to Huguier, to the mons 
veneris." 

It is more difficult to diagnose 
between abscess and a cyst of 
the excretory duct. In both 
cases we find, on one side of the 

Fig. 4?. Cyst of the duct of the vuivo- vulva, a globular tumor, of lim- 
vaginai gland. ite(] extent? springing- from the 

interior of the vulvar ring, and pushing the large lip outward; 
but incase of the cyst, it is smaller, indolent, without reactionary 




ABSCESS OF THE LABIA. 537 

and inflammatory phenomena; its greater diameter is directed 
according to the transverse direction of the excretory duct, and 
pressure causes the escape of a colorless fluid, slightly viscous but 
not purulent. 

It is very important not to confound an abscess of the labia with 
vulvar enterocele, lest you might plump a lancet into a hernial 
sac. The possibility of reducing the tumor by taxis, or of its 
disappearance in the recumbent posture, the impulse given to the 
tumor by coughing, and the absence of constitutional symptoms, 
are the signs by which you would know that a knuckle of intestine 
had been forced into the labium. 

Either with or without our help, these abscesses must be dis- 
charged ot their contents. It is a question whether more harm 
than good is not done by opening them too early. Guerih and 
Martineau have observed that fistulas are often caused in this way. 
The latter advises to wait for such an abscess to open itself through 
the mucous membrane or through the excretory duct of the gland. 
It generally breaks through the nympho-labial furrow, and the cure 
is speedy. If, however, the pain is very severe and the fluctua- 
tion is marked, it may be lanced in a direction that is per- 
pendicular with the labium. In some cases it is best to keep 
the wound open with a cloth tent or a bit of charpiethat has been 
wet with a solution of hydrate of chloral or of carbolic acid. When 
a fistula is formed, and the case becomes chronic, we need to dis- 
sect out the entire gland, which should be done very carefully on 
account of the haemorrhage. 

In the beginning such an abscess should be poulticed with 
slippery-elm or oat-meal. Flax-seed is objectionable in this 
case especially, because it becomes rancid. Dry heat applied by 
hot-water bags will give relief and hasten the suppurative process. 

For a simple, non-specific abscess of this gland the best internal 
remedy is phytolacca. When it is blenorrhagic, mercurius, or 
kali jodatus, is preferable. If the process of suppuration is very 
slow, you may give hepar sulphur, or perhaps nux vomica, as has 
been recommended for anthrax. If the discharge is copious and 
too protracted, silicea will be indicated. If there is great debility 
and prostration, with a depraved condition of the blood which 
tends towards sloughing and gangrene, arsenicum, lachesis, and 
the mineral acids are called for. The early constitutional symp- 



538 THE DISEASES OF WOMEN. 

toms, the fever and chilliness will respond to the usual remedies 
such as aconite, belladonna and bryonia. 

ECZEMA OF THE VULVA. 

Case. — Miss — age 23, came to the sub-clinic for the cure of an 
eruption about the anus and along the vulva, from which she had 
suffered for about four weeks. The attack was preceded by a dys- 
enteric diarrhoea with acrid and irritating discharges. The stools 
were very frequent but not very copious. When the eruption be- 
gan the bowel complaint ceased, and it has not returned, but in- 
stead she has had haemorrhoids. The vulvar and anal irritation 
are very much increased during the monthly periods. She has 
never suffered from any other eruption. 

A local examination revealed the existence of a patch of eczema 
which had evidently begun about the anus and extended over and 
beyound the labia majora. At some points there were vesicles, at 
others there were the dry scales of eczema. There was no 
vaginitis. Rhus tox., 3, internally, and Latour's collodian 
locally. 

She continued to report, and the treatment was not changed 
except temporarily to substitute Cantharis 3. for the rhus 
toxicodendron. But as the eruption declined a new set of 
symptoms appeared, and she began to show signs, of exfoliative 
endometritis, or a form of membranous dysmenorrhcea. This lat- 
ter condition was preceded by an evident extension of the irrita- 
tion, and possibly of the eruption also, along the vagina and to- 
wards the uterus. 

In Lecture XIV I have spoken of this class of causes for mem- 
branous dysmenorrhcea. The case before you shows the possi- 
bility of the direct extension of the vulvar eruption along the 
vagina to the uterine cavity, and also of a lesion of the uterine 
mucous membrane which shall result in its being moulted at the 
return of the menstrual period. 

VULVO- VAGINITIS. — PRURIGENOUS VULVITIS. 

Case. — Mrs. T , aged 45, English, married and the mother 

of eight children, was admitted to the hospital yesterday. She 
has never had a miscarriage. Three years ago she was troubled 
with a sudden arrest of the menses, which continued for eight 
months. They finally came on again spontaneously, and in the 
usual quantity, but the flow was subsequently attended with 
considerable pain. The climacteric was passed without any 
untoward symptoms one year a<ro. 



VULVOVAGINITIS. 039 

During the period of arrest of the catamenia, this patient was 
treated for ulceration of the womb, which, she says, was accom- 
panied by considerable discharge. At one time she remembers a 
sudden flow of " matter " which, she thinks, amounted in all to 
nearly or quite a tea-cup full. This discharge came suddenly 
"like the waters." There has been no trouble in micturition. 
The bowels have been constipated, and she has been annoyed with 
internal haemorrhoids which occasionally bleed. 

At present she complains of intense itching of the genitals, and 
says that pimples sometimes form on the labia and then burst. 
There is heat in the vagina, especially after exercise, and occa- 
sionally a slight, but never a copious, leucorrhcea. 

She also has considerable pain in the right leg, which extends 
from the right iliac region in front, around and over the hip, and 
clown the limb to the inner malleolus and the inside of the foot. 
This pain is not affected by changes of weather, but is aggravated 
by motion. The right knee-joint is enlarged, as in chronic 
synovitis. 

On physical examination the uterus was found in position, and 
of normal size. Examination with the speculum revealed the 
mucous membrane lining the vagina and reflected over the vaginal 
portion of the cervix to be studded with a papulous eruption 
resembling prurigo. The same eruption extends over the vulva 
and the adjacent integuments. 

This, gentlemen, is one of the old-fashioned women, whose 
maternal record is in every respect a creditable one. She has 

borne eight children, and has never suffered a 

miscarriage. If it were possible, I would take 
occasion to name all the physical and moral exemptions that she 
has enjoyed in consequence. Not the least among them is that 
she has escaped any serious illness at the climacteric. 

Three years ago, at the age of 42, she had suppression of the 
menses for eight months. Meanwhile she received treatment for 

ulceration of the womb, but whether she ever 
tion" Sre^the chin?™*" nad tnat disease, we do not know. It is very 

probable that her physician mistook the sup- 
pression for a sign of ulceration, and proceeded to cauterize her 
with a view to restore the catamenial flow. It is equally proba- 
ble that the menstrual arrest was due to a physiological and not 
to a morbific cause, or in other words, that it was a sign of the 
approach of the "change of life;" for, as I have already said, 
such intermissions in the performance of this function are by no 



An exceptional case. 



540 THE DISEASES OF WOMEN. 

means rare in women who have reached their fortieth year, and 
ib whom the period for its entire cessation can not be very dis- 
tant. 

The probable cause for such a temporary arrest, and which is 

apt to be overlooked, is a failure in the ripening of the ovule, 

and in the dehiscence of the Graafian follicle. 

Defective ovulation. . p ,.. , 

J3y-and-by the function ot ovulation is resumed 
and the menstrual flow re-appears. 

The muco-purulent discharge of which she speaks may have 

been due to a vicarious accumulation and retention within 

the uterine cavity, which finally found vent 

The sudden discharge. in _ r> -i i 

with the suddenness of a rupture ot the bag of 
waters. She could not have had an abscess without previous 
local pain and suffering, and general constitutional symptoms, of 
which she makes no mention. 

Constipation is the rule in similar cases, and a woman at 45, 
who has had eight children, can hardly have escaped haemor- 
rhoids. Concerning the latter I have questioned her carefully, 
and find that they are not inveterate. 

This prurigenous eruption is always accompanied by a loss of 

rest and sleep, constant irritation and distress. It is very apt to 

become chronic. The heat of the parts, and 

Symptoms. . . 

the torment sometimes occasioned by walking, 
sitting, intercourse, and physical exercise of every kind, are 
almost insupportable. If the characteristic peculiarities of the 
eruption have not been destroyed by the scratching and rubbing 
of the parts to which the poor victim is compelled to resort, the 
papulse resemble those of prurigo when it is seated on other 
parts of the body, as, for example, the neck, shoulders, back and 

outer surfaces of the extremities. So much of 

The eruption. n 

it as is located upon the cutaneous surface ot 
the labia, the perineum, and even about the anus, may be color- 
less and invisible, but if the parts have been wounded by fric- 
tion, you may perhaps find little black scabs scattered here and 
there. Sometimes, as in this case, there are occasional vesicles 
and wheals, which are readily discharged. 

On the mucous side of the raphe and within the vagina, how- 
ever, the color of the eruption differs from that of the surface 
upon which the papulae are located. This is especially true in 



VULVOVAGINITIS. 541 

the case of elderly women in whom there is no diffuse vaginitis, 
and whose vaginal mucous membrane has not 

The color of. . _ 

recently been discolored either by pregnancy 
or menstruation. But, in younger persons, in whom the opposite 
condition of this membrane prevails, there would be very little 
difference in hue between them. 

The causes of this peculiar affection are really unknown. It 
has been ascribed to various infractions of the rules of hygiene, 

such as the eating of unwholesome food, and 

the lack of proper clothing, cleanliness and 
exercise, to sexual excesses, to the change of life, and to the non- 
elimination by the proper emunctories of certain impurities from 
the blood. It may alternate with chronic skin disease. 

There is a form of granular vaginitis from which pregnant 
women sometimes suffer that should not be confounded with this. 

In it the eruption, or rather the pin-head pim- 
va5nuE° sIs fr ° m granular pies, consists of myriads of little granulations 

which give rise to pain, heat, and sometimes 
to considerable discharge. It is self-limited, is not accompanied 
by vulvar prurigo, and terminates with deliver}^. 

Prurigenous vulvitis, of which this is an example, can be dis- 
tinguished from the follicular variety by the fact that in the latter 

the lesion is limited to the follicles which are 

From follicular vulvitis. . . , . , 

found upon the vulva, and just withm the 
ostium vaginse. These follicles become inflamed and finally dis- 
charge a purulent or muco-purulent secretion which, in many 
cases, may be seen exuding from the mouths of the separate folli- 
cles. But these diseases often co-exist. Follicular vulvitis is also 
incident to gestation, and may occur as a contingent or sequel of 
the eruptive fevers, and of diphtheria. More frequently, how- 
ever, it is due to a very depraved and vitiated habit. Sometimes 
it is a sequel of gonorrheal inflammation. 

This form of vulvo-vaginitis not being purulent as it would be 
if the eruption were eczematous, or herpetic, or if the inflamma- 
tion were more diffuse and deep-seated, the 

The leucorrhoea. 

amount of the leucorrhceal discharge is not m 
proportion with the local suffering. Mrs. T. has but little flow of 
this kind. Where, however, the eruption and the inflammation 
extend within the cervix uteri, and possibly into the uterine cav- 



542 THE DISEASES OF WOMEN. 

ity, as there is good reason for believing that they sometimes do, 
the quantity of mucus and of pus secreted may be very large. 
In middle-aged and more vigorous subjects the presence of these 
little papulge (as in case of other vegetative growths within the 
vulva), may excite a very troublesome leucorrhoea. If the dis- 
charge that is poured out is thin and serous in character, it is very 
apt to dry upon the parts and then to crack and break into little 
scales which cause an intolerable pruritus. Some of these patients 
will tell you that they have no leucorrhoea, when in fact they are 
deceived and the discharge is disposed of in this way. In rare 
instances the eruption invades the urethra and occasions a very 
persistent and troublesome form of urethritis. 

The entire exemption of our patient from urinary troubles, such 

as strangury and the like, affords an indirect proof that she has 

not suffered from any variety of uterine devia- 

ceming uterine displace- tion. For this reason I felt almost confident 

merits. . 

that her womb was in situ before passing the 
sound. You remember that the attachments between the neck 
of the uterus and the bladder are such that it is next to impossi- 
ble to displace the former without pressing upon, or changing the 
position of, the latter. And when a woman tells you that she is 
not subject to, and has not suffered from, vesical troubles of any 
kind, you may be reasonably assured that her womb is where it 
should be. But you are not to conclude that because she has 
strangury, dysuria, etc., therefore her womb is displaced ; for 
these symptoms may arise from other and very different causes. 

The prognosis is generally favorable, but the time required for 
the cure will vary according to circumstances. Such cases recover 

more readily in winter than in summer, in cool 

Prognosis. . . . 

than m warm climates, and in young than m 
old patients. Scrofulous persons, and those who are predisposed 
to aphthous conditions, or to chronic cutaneous eruptions of what- 
ever kind, get well very slowly. The syphilitic taint may retard 
the cure. If it follows the climacteric very closely, or co-exists, 
as in the case before us, with rheumatism, we shall not be war- 
ranted in promising very speedy and permanent relief. 

Treatment. — As affording direct relief, and being capable of 
making life tolerable, the topical treatment is very important. 
The proper palliatives have already been mentioned when speak- 



INFANTILE LEUCORRHCEA. 543 

ing of pruritus of the vulva. Cleanliness, frequent bathing with 
cool or tepid water, and the application of a 

Topical treatment. , .. , , , , , 

bland demulcent, as bran-water, glycerine, 
almond oil with or without chloroform, or of the muriate of 
Irydrastin with glycerine, will answer an excellent purpose. 
Cloths or compresses anointed or saturated with one of these 
may be applied to the vulva ; or the cotton tampon may be the 
vehicle for introducing the same into the vagina. 

The diet should be plain and unstimulating, the exercise mod- 
erate, and coitus positively forbidden. 

The internal remedies should be suited more especially to the 

character of the eruption, the patient's peculiar clyscrasia, and 

the relation of the disease to child-bearing and 

Constitutional treatment. . , . 

the climacteric. Among the remedies that may 
be required in different cases are rhus tox., sepia, sulphur, arseni- 
cum, calcarea carb., conium, hydrastis, croton tig., carbo veg., 
mercurius, natrum mur., kali carb., creasotum, thuja and the 
mineral acids. 

Taking the peculiar eruption, and the incidental rheumatic 
symptoms as a guide, I shall select the rhus tox. as the remedy 
for this patient. She will take of the 3d attenuation a dose every 
three hours. This frequent repetition is justified in her case by 
the severity of her rheumatism. She will also have the glycerine 
and hydrastin applied locally morning and evening. 



INFANTILE LEUCORRHCEA. 

There is a form of vulvo-vaginitis to which little girls are liable, 
and of which I may speak in this connection. The mucous mem- 
brane reflected over the vulva becomes so in- 
flamed, heated and irritated, that the child has 
no rest, but is constantly tempted to relieve itself by rubbing the 
parts, which only increases the trouble and extends the inflamma- 
tion. Sometimes the first symptom complained of is pain on 
passing water, which also creates a sense of scalding and itching. 
This is accompanied by dryness, redness, and heat of the inflamed 
surfaces. Soon, however, the parts become moist from the exu- 



544 THE DISEASES OF WOMEN. 

dation of a thin, colorless mucus which, as the case progresses,, 
becomes of a thick and creamy consistence. 

The amount and quality of the leucorrhceal discharge varies 
with the constitutional taint, as well as with the duration of the 
disease. In scrofulous children, more espe- 
cially if they have been allowed improper food 
and have not been kept in a cleanly, healthful condition, the leu- 
corrhceal flow may be either very copious, or perhaps ichorous and 
corrosive. In bad cases of this kind there is not only inflamma- 
tion, but ulceration also of the vaginal mucous membrane. When 
these patches of ulceration are present, they may be seen by 
stretching the labia apart. More rarely they are found in the 
upper portion of the vagina. 

The causes of this form of vaginitis in children are numerous. 
Sometimes the urine has such acrid properties as by its flow over 
the vaginal surface to induce this disease. 
Simple catarrhal urethritis may develop into 
vulvo- vaginitis. Or it may arise idiopathically from exposure to 
cold, or a sudden check of perspiration. Sometimes it takes 
the form of an epidemic, and prevails in winter along with a more 
or less severe influenza. I have known it to alternate with a 
severe and troublesome coryza. It may attack several children in 
the same family or neighborhood. Irritation of the rectum, and 
sometimes of the colon, may induce it. In some instances it is 
due to the presence of worms that have escaped at the anus, and 
crawled within the vaginal orifice, where, by their presence, they 
excite a great degree of itching and irritation. And sometimes 
there is no doubt that it has been caused by a mischievous rub- 
bing and irritation of the parts by nurses and servants who have 
had the children in charge. 

The proper treatment for cases of infantile leucorrhcea is first* 
if possible, to remove the cause. It is very important to avoid 
exposure to cold and wet, and to order a proper 
and digestible diet. Cleanliness, bathing and 
drying the parts carefully afterwards, either with a very soft 
towel, or better still, with an application of finely pulverized 
starch, or lycopodium powder, as in case of infants to prevent 
intertrigo, are very useful. 

If the complaint is related to influenza, the internal remedies 



INFANTILE LEUCOURHCEA. 545 

will be the same as are suited to the epidemic catarrhal inflamma- 
tion, no matter where it is located. If it occurs in scrofulous 
children, the remedies which suggest them- 

Local and general. 

selves, and which are most useful, are calcarea 
carb., hepar sulph., and mercurius. A majority of cases may be 
cured with pulsatilla, or calcarea carb. 

If the passage of the urine occasions great suffering, give can- 
tharis, and have cloths that have been dipped in warm water 
applied over the vulva. If there is ulceration, or aphthous in- 
flammation, add hyclrastin or calendula to the water. If ascaricles 
have created the mischief, order lard to be smeared about the 
anus, or a decoction of garlic, or an injection of olive oil to be 
thrown into the bowel, and give the child teucrium. 

It is important that children who have this affection should not 

be allowed to sleep in the same bed, or to be washed with the 

same towels as those who are healthv. For 

Isolation. . " « 

although the disease is not always easy 01 com- 
munication, yet it might happen that it would spread through a 
whole family of little ones, and occasion much suffering and anxi- 
ety. It is a pleasure to be able to assure the mother or nurse 
that, with proper time and care, this disease may be readily and 
certainly cured. 

35 



LECTURE XXXIV. 

VASCULAR TUMOR OF THE MEATUS URINARIUS. 

Vascular tumor of the meatus. Non-specific urethritis. Causes. Symptoms; posture, 
quality of the urine. Diagnosis; from cystitis; from gonorrhoea. Treatment; rest, 
diet and drinks, general indications and local treatment. Urethral fever, and fissure 
of the urethra. Case.— Pathology of. Treatment; sitz-baths in, treatment for the 
vesical and renal complications, and for urethral lacerations. 

The refined and cultivated physician is sometimes at a loss to 
know when it is best to propose, and to insist upon the necessity 
for a physical examination of the female generative organs. He 
will not pander to the vulgar habit of resorting to this measure 
almost indiscriminately ; while, for the sake of his patient's wel- 
fare, as well as of his own reputation as a skillful diagnostician 
and practitioner, he must not postpone it too long, neither neg- 
lect it entirely. So important is this matter that a physician's 
reputation is sometimes made or ruined by the rumor that he is in 
the habit of using the speculum on the slightest pretext, or that 
he is opposed to its employment altogether. 

I am led to these reflections in consequence of the examination 
which I have just made of a case in the ante-room. This case 
had been attended by two physicians, one of whom pretended to 
have made a proper " examination" of the patient, while she 
refused to allow the other to do so. Both were wrong in their 
conclusions, and, consequently, neither of them did the patient 
any good. 

Case. — Mrs. T , 30 years of age, the mother of two child- 
ren, the youngest of which is four years old, has been in poor 
health for twelve months. One year ago she got her feet wet 
while menstruating. She has not been well since. Prior to that 
date her menstruation had always been regular ; but since that 
sudden check of the flow, the periods have returned every three 
weeks. There is no pain, but from time to time the flow is 
becoming more scanty. 

Soon after the taking cold she began to have trouble in passing 
water. The inclination to urinate was very frequent, and some- 
times quite irresistible. It was aggravated by being much upon the 
feet. Anxiety of mind, sudden good or bad news, and excite- 



VASCULAR TUMOR OF THE MEATUS. 547 

ment of any kind would induce a paroxysm. At first, but only 
for a short time, the urine was copious and colorless, but for many 
months it has been perfectly natural in quantity and quality. 
The only exception to this rule is that it has, once or twice, been 
d very little bloody. 

The only real pain experienced is after the flow of urine, or 
rather, while the last drops are running away. This induces a 
burning, stinging pain, which is peculiar, and " very dreadful," to 
her. Walking is painful, and, for some reason which she can not 
explain, intercourse occasions the most excruciating suffering. 

The first physician who treated her for this difficulty made an 
examination with the speculum, and after analyzing all the symp- 
toms that were gathered, pronounced her to be suffering from 
" disease of the kidneys." After some months of treatment with 
no especial reference either to the menstrual or the urethral diffi- 
culties, she changed her physician for one of more intelligence 
and experience. 

Her second physician prescribed for her for a time, and then 
requested permission to make an examination with the speculum. 
But it was denied, and he continued to treat her for " disease of 
the womb." 

The physical examination just made discloses a vascular tumor 
which is nearly the size of my thumb-nail, at and within the 
mouth of the urethra. It is very tender to the touch, and of a 
cherry-red color. The urethra around and beyond it is tumefied 
and evidently somewhat inflamed. The womb is in situ, and the 
os uteri has a healthy appearance. 

These vascular tumors, which are not at all infrequent, are 

very troublesome and often give rise to much suffering. They 

are located just at the mouth of the urethra, 

Nature and location. -,.,.. -i i • 

and within its canal, being attached thereto by 
a pedicle, like a polypus. They consist of a hypertrophy of the 
mucous papilla?, and are very vascular. Sometimes the tumor is 
lobulated ; more rarely there are two instead of one. The pedicle 
may be so slender as to break very readily when you seize the 
growth with a pair of small forceps ; or it may be firm and un- 
yielding. 

The symptoms accompan}dng such a case have already been 
detailed in this report. Painful and frequent micturition, espe- 
cially after exercise upon the feet ; pain upon 

Symptoms. . . 

walking, intolerance of coitus, and the most 
peculiar and exquisite suffering with the passage of the last drops 
of urine, are almost pathognomonic. These symptoms may con- 



548 THE DISEASES OF WOMEN. 

tinue until the patient is Tery weak and irritable. But the diag- 
nosis can not be made with certainty except by a physical 
examination of the parts involved. Indeed this examination must 
be visual, for unless you see the tumor, you can not be certain of 
its existence. 

The question recurs upon the necessity for such an examina- 
tion. This woman, who lives within a stone's throw of the 
hospital, has suffered for twelve months when 
«^inSio y n for physical sne m ight have been relieved in as many 
minutes. But two things were in the way of 
her getting well so speedily. The first was the ignorance of the 
doctor who examined her with a uterine speculum, and reported 
that she had " disease of the kidneys." How 
thifcas a e cles t0 recovery in this instrument could aid in the diagnosis • of 
renal disease, and what particular affection of 
the kidneys she was thought to have, I do not know. 

The second obstacle was her own shrinking sensitiveness, 
which would not permit the other physician (who was compet- 
ent) to do as he thought best. And so she has failed to obtain 
the hoped-for relief. 

How shall you act in similar cases ? The best rule that I can 
suggest is that you wait a reasonable length of time, providing 
the symptoms are not very urgent. Give the 
to^hysicXxpiofation 5 ^ appropriate remedies meanwhile, and place the 
patient under such hygienic regulations as will 
favor her recovery. But if the symptoms do not yield as they 
should, or if they show a decided tendency to relapse, the infer- 
ence will be that there is a local cause which perpetuates 
the mischief, and prevents a radical cure by internal means, alone. 
Under such circumstances a few sensible and cogent reasons 
addressed to the patient, will satisfy her of the necessity of a 
local examination, and obtain her consent thereto. You can 
explain the case by saying that the persistence of the symptoms 
and their liability to return when they have been relieved, leads 
you to conclude that they do not afford a reliable criterion of the 
nature of her disease. And, above all things, assure her before- 
hand that you will on no account proceed to operative interfer- 
ence, until the case is fully understood by both parties. 

This plan is as appropriate in a case in which the symptoms 



VASCULAR TUMOR OF THE MEATUS URIXACIUS. 549 

are connected with urination, where the quality of the urine is 
unaltered, as it is in cases of chronic and invet- 

Especially requisite . * ,. „ , ,, 

in diseases ot the erate uterine disease. I or you may be morally 
certain when you have given eantharis, mer- 
eurius, aconite, apis mel., cannabis, hyoscyamus, and kindred 
remedies, under appropriate indications, and relief has not fol- 
lowed, that the case needs a local examination, and perhaps topical 
treatment also. 

Treatment. — Excision is the remedy. You may seize the growth 
with a pair of delicate forceps, and snip it oif with a pair of sharp 
scissors, or the bistoury. Or ligation, or as- 
tringents and cauterization may answer; but 
they are more slow and painful. The stump, or point of attach- 
ment may be touched with the per-chloride of iron, or with a 
stick of the nitrate of silver, in case of haemorrhage. In order to 
prevent the subsequent growth of the tumor it may be necessary 
to repeat the application of the caustic after a few days. 

I have recently treated a case in which I had occasion to modify 

the usual means of excising these growths surgically, and the 

success of the experiment encourages me to 

a new mode of. recom mend it to the class. But I will first 

operating. 

give you the brief history of the patient's symp- 
toms and sufferings : 

Case. — Mrs. , aged 30, the mother of three children, the 

youngest of which was two years old, consulted me for the relief 
of urinary symptoms from which she said she had been suffering 
for a twelve month. Her physician had treated her constantly 
for nine months for uterine prolapsus. She had had applications 
of some sort made to the womb through a speculum, had worn 
a pessary, taken sitz baths, and tried electricity, both wet and dry, 
but without any relief. Local examination, by a direct inspection 
of the meatus urinarius, revealed a vascular tumor which evidently 
had blocked the passage and caused all the mischief. The uterus was 
not displaced, there was noleucorrhceal or menstrual trouble, and 
in fact no other lesion. 

It may seem to you that such a blunder in diagnosis would be 
inexcusable, but I assure you that the facts are as stated, and that 
the physician is a neighbor of mine who will feel very badly over 
it, if he ever learns how the case has turned out. My mode of 
operating was to seize the growth slowly but firmly with this pair 
of Pean's artery forceps. 



550 THE DISEASES OF WOMEN. 

When the blood had been thoroughly pressed out of the growth T 
a pin was passed behind the forceps transversely and its point cut 
off. After that, the forceps being* still attached, the elastic liga- 




Fig. 48. Pean's artery forceps. 

ture was applied beyond the pin, and the forceps removed. The 
pin kept the ligature just where I wanted it, no blood was lost, 
and the growth soon sloughed off. 

In a few cases, where the growth was so attached upon all sides 
of the meatus that it would have been very difficult to remove the 
whole of it without an extensive dissection, I have had good 
results from the local application of a strong solution of alum in 
carbolic acid. This does not cause very much pain, is always 
available, and may be repeated as often as is necessary. 

If the tumor is of the nature of the urethral haemorrhoids, blue, 
varicose and very vascular, care must be taken in its removal lest 
the loss of blood be considerable and troublesome. To avoid such 
a result, a needle may be passed and a ligature tightened so as to 
include the growth without cutting it off. If the tumor is very 
large, a needle armed with a double ligature may be passed and 
the threads tied both ways. 

. When the tumor is remote from the meatus, or high in the 
canal, it is a less easy matter to sieze it and to remove it satisfac- 
torily. In this case the easiest method is to sieze it with some 
form of a polypus forceps or snare, such as are used for removing 
polypi trom the nose or Irom the ear, and thus remove it. 

In case of cancerous growths within and around the meatus, I 
am satisfied that instrumental interference should be avoided. 

The after-treatment consists in keeping her in the horizontal 
posture for twenty-four hours or more, in order to avoid consecu- 
tive inflammation. If there are any signs of 
urethritis, it should then be treated as if the 
case was an idiopathic one. 



NOX-SPECIFJC URETHRITIS. 551 



XON-SPECIFIC URETHRITIS. 

Affections of the urinary organs in women are very trying to 
all concerned, not only because they are often difficult of cure, 
but also because of the suspicion and the fear on the part of the 
patient that they may be of a specific nature. It is for this latter 
reason especially that urethral difficulties are often permitted to 
continue for mouths, and perhaps for years, before the physician 
is consulted. From this delay the complications that ensue may 
not only undermine the physical health, but possibly the domestic 
happiness of the patient. 

Case. — Mrs. -, aged 28, has been ill for fourteen weeks. 

She is the mother of two children, the youngest of which is one 
year old. The babe was weaned at six months, since which time 
she has menstruated regularly. On the eve of the regular " period " 
she was seized with a strong desire to urinate, but, being " down 
tGwn on a shopping expedition," she could not conveniently re- 
spond. Although suffering great pain in consequence, micturition 
was deferred for more than an hour, during which interval she 
rode home, a long distance, in the street-car. But the simple 
evacuation of the bladder did not end her sufferings. For she 
still felt an almost irresistible call to urination, which has tor- 
mented her at intervals of from ten minutes to an hour ever since. 

The flow has never been involuntary. If she lies quietly upon 
her back, the irritation subsides, but the moment she turns upon 
either side the dysuria comes on again. Although in a less marked 
degree, standing and sitting produce the same result. She cannot 
sit in a chair five minutes without the most disagreeable sensations 
and throbbing, which are referred to the meatus and the course of 
the urethra. She says the pain is most acute and burning during 
the floAv. This pain is described as always of a burning character. 
The urine is sometimes cloudy, with a ropy sediment, but usually 
quite natural in appearance. It has never been bloody or highly 
discolored. The quantity voided in twenty-four hours is neither 
excessive nor deficient. 

Two years ago she had a similar attack, which continued for 
three weeks and appeared to subside of itself. Although her at- 
tention had not been called to the fact before, she now remembers 
that it followed a similar imprudence. She is quite positive that 
it bore no relation to the birth of her first child. This patient has 
already been under the care of several physicians, at whose pre- 
scription she has taken buchu, copaiba, oil of turpentine, and the 
usual drugs, including the extract of belladonna in large doses. 



552 THE DISEASES OF WOMEN. 

She has also made use of sitz-baths, suppositories, herb teas, etc., 
etc., but with only the most temporary relief. 

The uterus is prolapsed the moment she assumes the upright 
position, whether in standing or sitting. With this exception, the 
womb is normal in every respect. The vagina is not inflamed, 
neither is it especially sensitive, except along the course of the 
urethra. Pressure on that canal from above downwards causes 
the same pain of which she complains when passing water. It 
also forces the escape of a muco-purulent fluid from the meatus 
urinarius. The orifice of the urethra is more highly colored and 
tumefied than the surrounding mucous membrane. 

It is a singular fact that most writers upon the diseases of 
women have said little or nothing of this painful affection. We 
cannot attribute this oversight to its infrequenc}^ for, in the female 
subject, urethritis is much more common than stone in the bladder 
or cystitis, both of which diseases have received a due share of 
attention at the hands of the gynaecologist. Nor is it an insignifi- 
cant complaint. For whatever occasions such suffering as our 
patient has experienced, has a claim upon us for relief. 

Urethritis may be acute, sub-acute, or chronic. The two latter 
are the more frequent. It may arise from taking cold, more espec- 
ially during the menstrual period, getting the 
feet and limbs wet, sitting in wet skirts at 
church, or in the concert room ; from the extension of the inflam- 
mation in case of vaginitis along the mucous membrane of the 
urethra, or from the irritation of pruritus in the same canal ; vas- 
cular tumors of the meatus ; polypus of the urethra ; from acrid- 
ity of the urine; the contact of leucorrhceal discharges, or of 
vitiated semen ; from the pressure of a dislocated womb ; uterine, 
ovarian, hernial, or pelvic tumors ; cancer ; misplaced or illy- 
adjusted pessaries ; horseback riding ; mechanical injury during 
labor, or the induction of abortion by those who are ignorant of 
anatomy ; too forcible or too frequent coitus, especially at the 
month ; also from masturbation, gonorrhoea, syphilitic ulceration, 
urinary calculus, and indirectly from neglect to respond to the 
promptings of nature when the bladder should be emptied. A 
spurious form of this disease is sometimes met with in hysterical 
women. In the sub-acute variety the attack may recur with each 
menstrual period. 

The most prominent symptoms are burning and smarting or 



NON-SPECIFIC URETHRITIS. 553 

scalding along the course of the urethra, with frequent desire to 
urinate. In many cases this burming sensation 

Symptoms. . . . 

is continuous, being aggravated by the now ot 
urine. In others it commences when the patient is half, or, per- 
haps, wholly through with the act of micturition, and continues 
for some moments after the discharge is completed. The burning 
and the urging to urinate are increased by motion. Hence, if the 
patient persists in walking about, or sitting up, these symptoms 
Are aggravated. For this reason, she is generally better at night. 
She may find it possible to lie in a particular position, and in 
that only, with a relative degree of comfort. Thus, while our 

patient is easy upon her back, she cannot turn 

Posture chosen. . . . . . 

irom it upon either side without increasing the 
difficulty. Sometimes the erect position is intolerable. It is par- 
ticularly so if the case is complicated with prolapse of the womb, 
or uterine or other intra-pelvic tumors. The vesical tenesmus is 
very apt to be increased by the same cause. 

Usually, the character of the urine is not changed in any par- 
ticular, except that it is mixed with mucus. The blennorrhagic 

discharge may be quite profuse or scanty, ac- 

Character of the urine. t i i 

cording to the duration and gravity oi the attack. 
It varies, also, with the individual constitution, scrofulous persons 
being more apt to have a copious flow of mucus than others. The 
mucus is mixed with the urine when it is voided, but afterwards 
separates and settles as a cloudy, ropy material. It is never 
bloody. In very nervous women, after a paroxysm of strangury, 
there may occasionally be an abundant flow of pale, limpid urine, 
such as frequently follows a hysterical fit. 

When you visit such patients and inquire in general terms con- 
cerning their ailments, you will most likely be told that the}- have 
disease of the kidneys. For, however intelli- 

A domestic fallacy. 

gent in other matters, most women suppose that 
anything wrong with urination implies that the kidneys, and not 
the bladder or urethra, or both, are at fault. A diligent inquiry 
into the especial symptoms will enable you to discriminate between 
urethritis and nephritis, for example, and you should not, there- 
fore, be satisfied to prescribe upon the patient's diagnosis. 

Cases of this kind might, perhaps, be confounded with stone in 
the bladder. The pain at the close of, and after urination, the 



504 THE DISEASES OF W031EN. 

increased suffering and strangury from moving around during the 
day, and the frequent, scanty, interrupted flow 

Diagnosis— from stone. . . 

oi urine, are common to both arrections. But 
where the symptoms depend upon urinary calculus, we shall find 
them modified and supplemented by others which are lacking in 
urethritis. The pain caused by the contraction of the bladder 
upon the stone is sometimes acute, but generally of an aching 
character. And although it may extend along the course of the 
urethra, it is not accompanied by the burning sensation of which 

Mrs. complains. In stone, the urine is more or less bloody ; 

its chemical reaction varies with the kind of deposit ; the micro- 
scope detects an excess of some of its earthy constituents, and by 
"sounding" the bladder we recognize the presence of a foreign 
body contained within it. 

Cystitis is accompanied by more or less marked constitutional 
symptoms, as chill, fever, anorexia, and rapid loss of strength. 

The pain, which is referred to the pubic region, 

From cystitis. 

is in the first stage acute, lancinating, and ex- 
treme in degree when the bladder begins to contract. It is 
increased by motion, by pressure, and is worse at night during the 
febrile exacerbation. It may be of a burning character, but is 
more apt to implicate the rectum than the urethra. There is also 
a feeling of distension of the bladder. In advanced stages the 
abdomen becomes tender and tumefied, and in its further develop- 
ment the affection differs entirely from urethritis. 

It is extremely difficult, and sometimes quite impossible, to 
determine whether a given case of urethritis is or is not compli- 
cated with gonorrhoea. If the inflammation is 

From gonorrhoea. . _ ' . tit 

specific, the attack is more likely to be accom- 
panied by marked constitutional symptoms, by more intense suf- 
fering when the urine is passed, by a more copious discharge of 
mucus, and, what is still more characteristic, the more acute symp- 
toms subside spontaneously in from two to four days. But the 
particular history of the case, and especially the habits of the 
patient and of her husband, will help you to settle the question 
as between a benign and a specific inflammation in the urethra. 
Let me recommend, however, that, whenever it is possible, you 
shall give all parties concerned the benefit of a doubt, and pro- 
ceed to the* relief of the symptoms which are actually present. 



NON-SPECIFIC URETHRITIS. 555 

Treatment. — Perhaps no better opportunity will offer in which 

to say a word concerning the length of time required for this and 

similar diseases to recover under proper treat - 

Rapid cures exceptional. . 

ment. In some of our books and journals you 
will find it reported that a single dose has cured such a patient 
almost instantly. The inference is that if we prescribe carefully 
and accurateky, the relief will be certain and speedy. The truth 
it often quite the reverse. Such a case as this, one in which a 
poor woman has been ill with marked and decided local inflamma- 
tion for many weeks, must, in the nature of things, convalesce 
slowly. And so is it with the majority of diseases that the physi- 
cian is required to treat. 

The ill effects of motion are so manifest in urethritis that the 
first condition prescribed should be rest in the recumbent position. 

The patient may be allowed to lie on the back, 
P oSdon in the recumbent or upon either side, as she prefers, but should 

not be permitted to stand, sit, or walk about. 
Riding would be equally injurious. She should as much as possi- 
ble refrain from doing anything which would increase the pain or 
the frequency of urination. For this reason, it is best to pre- 
scribe sexual abstinence also. 

The diet should consist of plain, wholesome food, which is 
freed from condiments and easily digested. All kinds of wines 

and liquors are poisonous. Tea may be allowed 

The diet and drinks. . L . r J 

in moderation. Ihe meals should be taken 
regularly. Vegetables are better than meats for these patients. 
If she eats an excess of sugar her sufferings may be greatly 
increased in consequence. Diluent drinks, as rice water, gum 
arabic, an infusion of flaxseed or of slippery elm, may mitigate 
the suffering by rendering the urine less stimulating and acrid. 

If the case is at all obstinate or chronic, a careful examination 

should be made of the meatus urinarius, the urethra, and adjoin- 

, . ing organs. If there is a vascular tumor at the 

General indications. . 

orifice, or a polypus in the canal, remove it by 
the scissors, ligature, or caustic, as you think best. If the uterus 
is displaced, correct the deviation and cure the remaining symp- 
toms with appropriate internal remedies. If the inflammation is 
a sequel of vaginitis, or of pruritus of the vulva, treat it as you 
would have treated the idiopathic affection. And so likewise if it 



556 



THE DISEASES OF WOMEN. 



For gonorrhoeal 
urethritis. 



is incident to leucorrhoea or any form of menstrual derangement. 
In gonorrhoeal urethritis, especially if there is considerable 
inflammation and heat in the vagina also, I know of no remedy 
so well adapted to the relief of acute symp- 
toms as atropine 3. Besides this we have 
aconite, cantharis, cannabis sativa, and mercu- 
rius, which may be given under appropriate indications. 

Simple, uncomplicated cases may require cantharis, cannabis, 
conium, belladonna, mix vomica, calcarea carbonica, hepar sul- 

phuris, or mercurius corrosivus. Mrs. will take a dose of 

cantharis 3d once in three hours. 

The local treatment is simple, and sometimes very useful. I 
have many times relieved the suffering and hastened the cure by 
thoroughly anointing the urethra with cosmo- 
line, or vaseline as a vehicle for hydrastin. To 
apply it you may wrap a long and slender dressing forcep tightly 
with cotton, smear it with the cosmolineand, passing it carefully 
along the urethra allow it to remain there for the space of five 
or ten minutes. 

Or, medicated injections containing glycerine, warm water, 
and the same remedy that is being given internally 'may be ap- 
plied through such a syringe as this. (Fig. 49.) 



Local treatment. 



Fig. 49. The uterine and urethral syringe. 

In case the attack of urethritis is complicated with inflamma- 
tion and induration of the cellular tissue about the passage, or if 
it is gonorrhoeal and relapsing, the hot water 
douche is of exceeding value. Water as hot as 
the patient can bear it may be thrown through a catheter like this. 
{Fig. 50.) 



The urethral douche. 




Fig. 50. Skene's reflux catheter. 

You should not forget, however, that in the healthy state, or 
when it is not dilated, the female urethra will not hold more than 
from eight to twelve drops of liquid at one time. 



URETHRAL FEVER. 557 



URETHRAL FEVER, AND FISSURE OF THE URETHRA. 

Case.— Mrs. aged 33, has never had a child or a miscar- 
riage. One year ago, when living in Michigan, she was ill with 
bilious fever, which continued four or five weeks. At this time 
the kidneys were somewhat involved and she began to have nerv- 
ous chills, which came regularly twice a day lor a while, gradu- 
ally increasing to four or five in number daily. The chills 
continued in this way some weeks, but since coming to Chicago 
she finds that they are decreasing in number and severity, so that 
now she has but two daily, at 10 a. m. and at 3 p. m. Some- 
times she can prevent them by moving about. She says she does 
not feel cold, but there is a chilly trembling sensation all over 
her body, her eyes run and she feels as if she had taken cold. 
There is no sweat following the chill, although there is sometimes 
fever. She sleeps well and is never awakened by a chill. The 
menses are regular, but of too long duration and are too copious. 
She has some headache during the chilly stage, and her feet and 
limbs feel numb. The urine is sometimes scanty and sometimes 
copious, and the bowels are habitually constipated. She has 
never had haemorrhoids, and can lie upon either side. Ignatia 3 
four times a day. 

Oct. 27. She has had two chills in the forenoon and one in the 
afternoon, lasting from half an hour to an hour. At the onset 
her head becomes dizzy, and there is a desire to yawn, and the 
feet become cold. She says that of late, during the menses she 
has pain in the back and down the outside of the limbs, and also 
in the left breast, but none in the pelvis. The eyes are very sen- 
sitive to light during the chill, (there is a marked nystagmus.) 
Gelsemium 3. 

.Nov. 3. She is not much better and has considerable pain in 
the region of the sacrum. There is a drawing pain in the muscles 
of the neck, extending up into the head. Macrotin 3. 

Nov. 10. Although the chills still continue she is in some 
respects better, but there is a feeling of heat on the top of the 
head and her feet are very cold. Sulphur 30. 

Nov. 24. She still has three chills every day. There is no 
fever, but she feels dull and stupid after the chill. About 3 or 4 
a. M, during the past week, she has been awakened with a sensa- 
tion of coldness between the shoulders, and she cannot get warm. 
She now tells us that about one year ago she had an attack of 
inflammation of the urethra, and was ill some time, and she has 
pain now when passing the urine. Some days she must void it 
every half hour, and must get up quite often at night to urinate. 
She has observed that the urine is sometimes clear and again it is 
clouded. These symptoms are not aggravated at the menstrual 
period. Thlaspi bursa 3. 



558 'IHE DISEASES OF WOMEN. 

Dec. 1. The chills still continue. Straining to urinate, as she 
sometimes must, will induce one. To-day she has a flushed face 
and some fever. Her appetite is good, but she has not been able 
to eat salt food for some time, because it always aggravates the 
urinary difficulty. She has not been obliged to get u«p at night as 
often, but during the day she must urinate four or five times. She 
has had treatment for urethritis. Thlaspi bursa 3. 

Dec. 3. Local examination before the sub-class revealed swel- 
ling and tenderness along the course of the urethra. The meatus 
was protruded, very reel, and sensitive. Pressure along the 
urethra, from the neck of the bladder forward caused considerable 
pain, but did not bring away any discharge. There was a slight 
coincident vaginitis. 

This affection, which for the lack of a better name is called ure- 
thral fever is compounded of a nervous predisposition, a miasmatic 
exposure or experience, and a local non-specific 

Pathology of. . * ! ' l 

inflammation ot the urethral mucous membrane. 
It is the outgrowth of a peculiar cachexia, which the experienced 
gynaecologist should be able to recognize at a glance. 

The case before you illustrates the necessity of a local examina- 
tion before an accurate diagnosis can be reached, or an intelligent 
prescription can be made. It also shows that the adaptation of 
the remedy to the epi-phenomena is not always easy or successful ; 
and that a slight local inflammation which is remotely located 
may be sufficient to perpetuate some of the symptoms of a mias- 
matic fever, and finally to develop a cachexia that is almost as 
enigmatical as hysteria or hypochondria. 

In prescribing for urethral fever you should proceed in the same 
manner as in a case of menorrhagic fever, giving the first, and 

the most prominent heed to the local symptoms. 

Some of these cases can be cured by the regular 
practice of drawing off the urine with the catheter. In others relief 
will come with allowing. a Sims' catheter to remain in situ. 



& 



When these cannot be borne it may be well to order the 
warm hip-bath, which can be continued for several minutes and 
repeated four or five times daily. It is not a bad rule to 
advise that such a bath shall be taken as often 
as the chill returns, or in anticipation of it. 
For this chill is a kind of outlaw, or a spurious affair at the best, 
and you may sometimes dispose of it by an expedient that will 
divert the patient's attention. In cases which are complicated 



URETHRAL FEVER. 559 

with pelvic peritonitis the good effects of the sitz-bath will be 
enhanced by taking a vaginal or a rectal injection of hot water at 
the same time. 

Nor should you forget that the condition of the urine as revealed 

by chemical examination, and by the microscope, may afford the 

most important therapeutical indications. In 

For the vesical and e h case WQ should look for the pre sence 

renal complication. J L 

of mucus, pus, epithelium, blood cells, alkalinity, 
and the absence of urea, and when either of them is found, be very 
careful to interpret its clinical meaning correctly. 

Cases of urethral fever sometimes depend upon a laceration of 
the mucous membrane about and within the meatus, which lacera- 
tions are likely to develop into linear ulcers 
uSnra? erati0nSOf ^ that are vei T painful and difficult of cure. In 
the puerperal state especially, they may cause a 
high degree of fever and give you much trouble. Local applica- 
tions made directly to the wound will give the greatest relief. 
Nitric acid 2, hydrastis 2, or, if there is suppuration, calendula, 
may be mixed with glycerine and used in this way. Dr. Shears, 
our house physician, has recently cured a very interesting case by 
the application of the oleaginous collodion. When this lesion has 
become chronic, the best thing to do is to resort to the local appli- 
cation of iodoform (which, when mixed in equal parts with the oil 
of sweet almonds, has no bad odor). 
This can be used in emulsion with the oil, 
or by means of a slender gelatinous sup- FlG - 5L Duncan's suppository, 
pository, which can be passed into the urethra and allowed to 
dissolve. (Fig 51.) 

I have given you the details of this case until the present, just 
as they were recorded by Mr. Dow, our clinical clerk, and they 
will serve to show you that one of your teachers at least, cannot 
treat these cases properly without a little time and thought, and 
without an analysis of the symptoms and conditions that are pre- 
sented. This patient should have had mercnnus cerrosivus 6 t a 
month a«"o. 



LECTUKE XXXY. 

CYSTOCELE. — HERNIA OF THE BLADDER. — VAGINAL CYSTOCELE. 

VESICOCELE. 

Cystocele. Symptoms. Case.— Varieties of; treatment, mechanical, and surgical. On dila- 
tation as a means of diagnosis in diseases of the bladder and of the urethra. Vesical 
inspection and palpation. The catheterization of the ureters. Hysterical ischuria. 
Case. 

Case. — Mrs. H., aged 39, married, is the mother of two children, 
the eldest of which is five and the youngest is three years. About 
six months ago she began to have a discharge from the vagina, 
with severe bearing down pains. At first she thought she had 
falling of the womb, but now she thinks the bladder comes down, 
because when the swelling is the largest so as to protrude a little 
from the vulva, she has to push it back before she can urinate. 
There is considerable soreness of the parts, and not much pain on 
urinating, but the urine contains a considerable quantity of red 
sand and mucous sediment. The menses are regular, but just 
before the period there is increased inflammation and tenderness 
about the bladder especially. When the tumor protrudes it 
obstructs the vagina so that it is possible only to pass the nozzle 
of the syringe, the tumor is very sensitive, and the pain does not 
cease upon lying down, its protrusion is produced by over exertion, 
after which it remains for two or three days and then may disap- 
pear of itself. She is very nervous and restless, and does not sleep 
well. 

Dec. 3. A local examination in the presence of the sub-class 
showed vaginitis with swelling and deformity of the urethra. The 
p?«rts are very sensitive. A female catheter was introduced and 
its point passed downward toward the hollow of the sacrum. 
The touch showed that the bladder and the uterus were both pro- 
lapsed. On lifting the bladder to its normal position the catheter 
pointed in the right direction, behind the symphysis pubis. 

There are three cases of vaginal cystocele now in our clinic, 
which shows that the affection is not a very rare one. This is not 

a very bad case, but in most respects it is typical. 

It shows the union of prolapse of the bladder 
with prolapse of the uterus, and of the vagina. It shows concur- 
rent vaginitis, the inability of the patient to urinate until she has 

56J 



CYSTOCELE. 561 

reposited the tumor, and the liability of the urine to undergo 
alkaline decomposition when it is retained in the pouch that is 
formed by the prolapse of the bladder. It also shows the absolute 
sign of cystocele as revealed by the passage of the catheter. 

There are four varieties of vesical hernia, viz., the inguinal, 

the crural, the perineal, and the vaginal. The two former occur 

very rarely, and only in men ; the two latter 

varieties of cysto- -. j womeu _ Perineal cystocele is sometimes 

cele. J J 

contingent upon pregnancy, and disappears after 
delivery. Boyer ascribes it to the pressure of the uterus and of 
the foetus upon one side ot the pelvis more than the other. 

Vaginal cystocele is most common with those who have borne a 
number of children, but it may happen in young girls, and in those 

who have been married without becoming 
cyttoceie! ^^ mothers. The pathognomonic signs of this affec- 

tion are the formation of a tumor at the anterior 
and upper portion of the vulva, which is largest when the patient 
stands erect; which disappears or is easily reduced when she lies 
down; which is covered with transverse wrinkles when the blad- 
der is empty, and smooth when it is full, which interferes with 
urination until it has been reposited, and in which the urine may 
accumulate until it has become ammoiiiacal, or even until calculi 
have been formed therein, and the change^ in the direction of the 
urethra, so that when the catheter is passed the axis of the blad- 
der is entirely changed. 

Whether this form of hernia of the bladder depends upon the 
prolapse of the uterus and of the vagina, or if it has preceded it, 
cannot always be known ; nor is it of very great practical im- 
portance to speculate upon it. It is enough to know that the 
clinical indications are identical, and that the cure of the case 
requires that both and all of these 
parts should be reposited, and 
kept where they belong. 

The treatment is either mechan- 
Treatment. ical or surgicaL 

With a view of 
supporting these parts, various 

pessaries have been devised, of FlG - 52 - Skene's pessary for cystocele. 

which Dr. Skene's is in more general use than any other. 

36 




562 



THE DISEASES OF WOMEN. 



My friend Mr. George E. Halsey, of Halsey Brothers, pharma- 
ceutists in this city, has devised a 
modification of the Shannon supporter, 
which is very simple 

Case. 

and at the same time 
very useful in cystocele. If ^ou ever 
have a case of this kind, I recommend 
you not to forget this instrument. A 
lady sixty years of age had had cysto- 
cele for twelve years, during which 
time she had used various expedients 
to keep the bladder in position. She 
then began to wear Halsey's pessary 
for prolapsus of the bladder, and she 
told me only a few days ago that she 
has now worn it for two years with 
entire relief, and I know that she is a 
truthful witness. 

In the American Journal of Obstet- 
rics for July, 1880, you will find an 
illustrated description of Gehru ug's 
ante-version pessary as adapted to the 
treatment of cystocele and procidentia 
uteri. The paper gives the details ot 
eight case^ of cystocele that have been 
cured by it in the hands of different 
physicians. Here is the instrument, which requires to be intro- 
duced with about the same manipulation as 
a Hodges pessary. 

Various surgical operations have been 

practised for the radical cure of vesicocele 

which, en passant, are 

Operations f or cysto- equa ] ly applicable ill recto- 
cele and rectocele. *■ J L L 

cele. Huguier's method 
consisted in dilating the urethra with the 
sponge- tent, so as to permit the introduction 
of the index finger of the left hand into the fig. 54. Genrung's ante- 
bladder. The anterior wall of the vagina version pessary, 
was then seized with the Museux forceps and dragged down 




Fig. 53. Halsey's pessary for cys 
tocele. 




CYSTOCELE. 563 

wards and forwards so as to separate it as far as possible from 
the corresponding- walls of the bladder, after which several long 
pins were passed so as to cross each other be- 
neath the vaginal fold, and through the cel- 
lular tissue which separates the vaginal and vesical walls. Care 
was taken not to pierce the bladder, by means of the finger 
which Avas retained within it, after which a wire loop was 
thrown about and below the pins, and the vaginal fold was tight- 
ened. The final step consisted in applying the ecraseur so as to 
remove the redunclent tissue. The same operation, but with the 
finger in the rectum as a guide lor the pins, was made for recto- 
eel e. 

Jobert (de Lamballe) removed several longitudinal bands of the 
mucous membrane from the anterior wall of the vagina and 
stitched the incisions together, taking the pre- 
caution to leave a flexible catheter in situ in order 
to prevent the contractions of the bladder 
while the healing process was going on. 
Yidal (de Cassis) advised to form a cica- 
trix by means of applying a number of 
serra-fines, which may 

Vidal's oppration. . ., , . 

be allowed to remain 

until the parts of the vaginal mucous 

membrane included have sloughed away. FlG . 55 serre-fines. 

The operation which I prefer, both for cystocele and rectocele, is 

that first practised by Professor Stoltz, of Nancy, 

Stoltz's operation. \_ . \. . ' . J ' 

h ranee. Here is a diagram which will give you 
a better idea of it than a mere verbal description. Fig. 56. 

Colporrhaphy, or elytrorrhaphy, is an operation designed to 
narrow the vagina so as to prevent the prolapse 
J ° P cy r stoc?ief or of the bladder, the uterus or the rectum, or of 
all of these organs at the same time. Of the 
various methods designed for the cure of cystocele, that of Stoltz 
is the best. It consists in denuding the vaginal surface of the 
tumor in a circular form and in passing the suture along the mar- 
gin of the wound, so that it may be closed like a big hole in a 
stocking. 

The patient is placed in the lithotomy position, and the paring 
must be done very cautiously lest the bladder be injured; and for 
the same reason the needle must not be passed too deeply into the 




564 



THE DISEASES OF WOMEN. 



tissues. The suture is run in as a seamstress "gathers" the linen 
on her needle. It should be of strong, but fine and pure silk that 
has been carbolized or of the colored silk- worm gut. The most im- 
portant part of the after treatment is to prevent such an accumu- 
lation of urine as would have a mischievous effect upon the proper 
healing of the wound. After the second day vaginal injections of 
calendula, glycerine and warm water may be given once or twice 
a day. The suture may be removed at the eighth or ninth day. 





Colporrhaphy for 
rectocele. 



R#*3 



C 

Fig. 56. Stolz's Method. 

Most cases of rectocele are accompanied by perineal laceration, 
and can be disposed of by the operation of colpo- 
perineorrhaphy. This result is secured by carry- 
ing the line of freshening well up over the sum- 
mit, and by passing the suture so as to draw that summit into 
the perineal wound, which will shorten the posterior vaginal wall, 
make the perineum firm, and furnish a means of support for the 
prolapsed or retro-verted uterus. 

If, however, the rectocele is a large one, forming a tumor that is 
forced out of the vulva, two operations will be necessary. First, a 
colporrhaphy should be made in order to dispose of the redundant 
vaginal tissue, and to narrow that passage ; and afterwards, if there 
are no reasons to the contrary, it may be followed by perineorr- 
haphy. The operation is similar to the one just described, except 
that the form of the freshened surface may vary according to cir- 
cumstances, and that the sutures may be crossed transversely. 



DILATATION OF THE URETHRA, ETC. 



565 



Because of the strain upon the wound and the probability that 
*-*, ^ the sutures will need to be left in place for 
a fortnight or more, they should be of silver 



"mat 



^ wire. 




Fig. 57 



c 

Stoltz's method, 
the wound closed. 



Case. — Mrs. , aged 62, was sent to the 

hospital by Dr. Thomas Gillespie, of Keno- 
sha, Wis., for relief from what proved to be 
a rectocele. The tumor was as big as a very 
large orange, and protruded from the vulva. 
She had suffered from carrying it for about 
twelve years, and always supposed that it was 
the uterus. The operation was made before 
the class and consisted in freshning a large 
oval surface on the vaginal side, and carefully 
closing the wound with silver sutures, of which there were twenty 
in all. The bowels were kept soluble ; the wound was washed, after 
the second day, with a mixture of calendula, glycerine and warm 
water and the diet was restricted to fluids and light soups. At the end 
of three weeks ten of the sutures were removed, at the end of four 
weeks, the last ten were carefully taken. The result was perfect 
in every particular; the tumor had disappeared, the cicatrix had 
healed completely, and the bowels were regular and moved with- 
out pain or soreness of any kind. 

I am satisfied that a very 
important step of this oper- 
ation is to carry the sutures 
across the freshened sur- 
face of the wound, so that 
they shall always be ex- 
posed at the mesian line, a 
precaution which brings 
the two flat surfaces to- 
gether when the wound is 
closed, and which prevents 
an undue strain upon the 
edges of the wound. Fig. 58 




Fig. 58. The Sutures in situ. 



ON DILATATION OF THE URETHRA AS A MEANS OF DIAGNOSIS IN 
DISEASES OF THE BLADDER AND URETHRA IN WOMEN. 



Some of you are already familiar with the fact that the female 
urethra may be so dilated as to admit of the introduction of the 
index finger. You have seen me perform this operation by means 
of the dressing forceps, Atlee's uterine dilator, and the sponge- 



566 THE DISEASES OF WOMEN. 

tent. Of late this expedient has been quite frequently resorted 
to for the removal of stone from the bladder without cutting. 

Here is a sponge-tent that I wish you to examine carefully. 
Ten minutes ago it was removed from the urethra of one of my 

lady patients, and it presents some appearances 
sptn^e-Teirt 56 f0r the Wn feh it is quite probable you have never before 

observed. Its base is as large as a silver dol- 
lar. It is of unusual length, and is composed of the best sponge. 
Excepting only at its smaller extremity, it is as clean as if it had 
just been washed. There is not a shred of mucus or a drop of 
blood upon it anywhere else. At its tip, however, you will see a 
quantity of pus which is slightly streaked with blood. 

My patient has been ill for some weeks with a violent, non- 
specific urethritis. Under the appropriate treatment, which I 

have already detailed to you the inflammation of 

Case. 

the urethra was entirely cured. But there re- 
mained a frequent desire to urinate, inability to retain the urine 
for more than an hour at a time (unless she was riding in her car- 
riage), an occasional deposit of a creamy-looking matter in the 
bottom of the vessel, and more or less of vesical tenesmus. Some 
of the symptoms resembling those of stone in the bladder, and all 
of them failing to respond to the usual remedies, I determined to 
dilate the urethra for the purpose of further exploration. This 
was first clone by means of the instruments named, and afterwards 
by the introduction of a series of long sponge-tents at intervals 
of three days. Each time that I have removed the tent it ha& 
presented the appearance so well shown in this specimen. 

The use of the tent in this case enables me to locate the seat of 
the ulceration very definitely. I know by the appearance of the 
sponge that the urethra is in a healthy state, and that the pus 
which has been discharged with the urine came from some portion 
of the bladder. Having stretched the vesical sphincter with the 
dilator, so that the urine escaped freely, and afterwards intro- 
duced the tent to the same distance, by actual measurement, I am 
confident that its tip was applied to and within the neck of the 
bladder. The thick, creamy pus, which has been brought away 
by the sponge, was not sufficiently fluid to have run clown from 
the cavity of the bladder, but was evidently taken up by it directly 
from the diseased surface at its neck. The distal extremity of 



DILATATION OF THE URETHRA, ETC. 567 

this sponge looks exactly as if it had been applied to a suppurat- 
ing ulcer on the integument. 

I am, therefore, justified in feeling as confident in the diagnosis 
of ulceration of the neck of the bladder in this case, as if I had 
seen the ulcer. Indeed this means of exploration has certain ad- 
vantages over the endoscope as applied to diseases of the urinary 
passages in the female subject. It is more simple and available. 
It does not require an especial and expensive instrument. It 
furnishes a sample of the discharge, and dilates the urethra so as 
greatly to facilitate the local application of remedies, if it shall 
be deemed desirable. 

There is no harm in dilating the temale urethra quite rapidly. 
For this reason, and because it lessens the duration of suffering, 
we choose a freshly-made tent, one that will 
soften and expand very readily. The patient 
should be placed upon the back, with the hips brought to the 
edge of the bed. The feet may be put each in a chair at the side 
of the bed, as if you were intending to apply the obstetric for- 
ceps. Then take Atlee's uterine dilator, or the long dressing for- 
ceps, have them well oiled, or anointed with glycerine, or with 
soap from the dressing-table, introduce them carefully into the 
urethra, and separate the blades so as to stretch the passage from 
right to left, and from above downwards. Upon the removal of 
the instrument the tent can be pushed in carefully and steadily, 
until it has reached the neck of the bladder. Hold it there for a 
few moments until it begins to soften, else, being pointed and 
somewhat conoidal, it may be forced out by a sort of peristaltic 
spasm of the adjacent muscles. Ynu may leave it within the 
urethra for from half an hour to one or two hours, but not longer. 
For it will soften and dilate much more rapidly than if it were in 
the canal of the uterine cervix ; and besides, an early removal 
will give you a better idea of the condition of the neck of the 
bladder than if it were allowed to remain for any considerable 
time. It need not be carbolized. 

If the passage is very narrow, or has been inflamed, it is better 
to begin with a small-sized tent, and afterwards to use larger 
ones. The sponge is certainly preferable to the sea-tangle, or 
slippery elm and other material, because it is less hard and irri- 
tating when first introduced, and because it does not need to be 



568 THE DISEASES OF WOMEN. 

retained so long in the urethra. The bladder should be emptied 
before beginning the operation. 

I have used the tent also in very obstinate inflammation of the 

urethra, and have thus been enabled to recognize, locate, and 

treat, an ulceration of its mucous membrane 

The tent in urethritis. ^^ movQ direct J y Jmd successfully than Icoulcl 

otherwise have done. The topical employment of remedies to the 
inflamed urethra might easily be secured by means of medicated 
tents and bougies. 

In dilating the urethra for the purpose of bringing medicated 
substances and injections in contact with the neck of the bladder, 
and with the upper portion of that canal, it is 
best to stretch it only at its inner extremity, by 
means of one of the instruments named. This leaves it funnel- 
shaped, and, while the patient lies upon her back with the hips 
raised, secures the retention and contact of the substances injected. 
An ordinary hard-rubber intra-uterine syringe will answer a bet- 
ter purpose than a more complicated one for throwing these injec- 
tions into the female urethra, and even into the bladder, when it 
is necessary. Or you may use a Nott's hard rubber syringe, with 
the straight pipe, being careful not to apply too much force. 




Fig. 59. Nott's hard rubber syringe. 

Vesical Inspection and Palpation. — Dilatation of the urethra 
has also been practised for the purpose of examining the interior 
of the bladder by the eye and the touch. The late Dr. Grustav 
Simon devised vesical speculse, of various sizes, the largest being 
about an inch in diameter, which could be passed through the 
'urethra so as to expose the lining membrane of the bladder. The 
patient being anaesthetized, a small incision is made on either side 
of the meatus, the urethra is stretched as already described, and 



DILATATION OF THE URETHRA, ETC. 



569 



the speculum is passed slowly and carefully. Only five to tea 
minutes are required to dilate the urethra in this way. 

A better instrument, however, is Dr. Skenes', endoscope, which 
can be applied more easily, which you can find in the instrument 
shops, and which can be used with the sunlight or with a strong- 
artificial light by the aid of a concave mirror. 




Object of intra- 
vesical inspection. 



Fig. 60. Skene's urethral endoscope. 

The practical value of this inspection of the interior of the 
bladder, realized in certain cases of cystitis, of 
chronic ulceration, and of foreign growths with- 
in the oro-an. 

For visual inspection of the urethra only, you may use a cylin- 
drical speculum like this. (Fig. 61); or, if you want to look jus 
within the meatus, a common ear-spec- 
ulum will sometimes answer the pur- 
pose. 

Vesical palpation is not difficult es- 
pecially after dilatation of the urethra FlG - 6l - Urethral speculum, 
with the endoscope, or such an instrument as Hunter's uterine 
dilator. 

When passing the index finger into the urethra, the second 
finger should also pass along the vagina so as to include the vesico- 
vaginal septum between them. The object of 
paction! intra " VeSiCal the touch as applied to the inner surface of the 
bladder is to recognize the hypertrophy of the 
organ in chronic cystitis, the presence of vegetative growths and 




570 



THE DISEASES OF WOMEX. 



of foreign bodies within it, for the diagnosis of defects in the 
vesico-vaginal septum when the vagina is closed, and for the detec- 




Fig. 62. Hunter's uterine dilator. 

tion of fissures at the neck of the bladder and in the urethra. It is 
also employed in the vesico-uterine touch of Noeggerath* and for 

6BK 



TrZ 




Fig. 63. h BW., Posterior wall of bladder ; B Gr., Fundus; Tr. L, Trigonum Lieu- 
taudii: fob, Opening of the ureters; aaa, Ligamentum interuretericum. (The distance be- 
tween the vesical opening of the urethra and the ligamentum interuretericum is too 
great as here represented.) 

the detection of the probe in catheterization of the ureters. Here 
is a diagram that will give you an idea of Simons' method of 
sounding the ureter, by passing the instrument along the finger 
to and within the orifice of that tube. 

Concerning the danger of digital palpation, and dilatation of 
these parts, Dr. Simon says : 

*See Page 83. 



HYSTERICAL ISCllURIA. 571 

** Within two years and a half, the time I have been practising- 
digital palpation of the bladder, over sixty cases came under 
observation in the Heidelberg clinique. Generally, palpation 
was carried out by us repeatedly in one sitting and by several of 
our medical brethren, who happened to be in our clinique at the 
time, yet, as I stated above, no serious consequence was ever 
witnessed. By so great a number of palpations of the bladder, 
every scruple which might have been brought forward against it 
ought now to be put aside, and this method of exploration, which 
was formerly only permitted in some rare cases and by specialists, 
should become the common property of every medical man.'' 

In my judo-men t, and as the result of experience, this statement 
needs to be qualified. For it is possible to expand the urethra to 
such a degree as to rupture its walls; and Em- 
met and others have known dilatation to be fol- 
lowed by incontinence. It is always important to remember that 
the calibre of this canal may vary in different persons, at different 
ages, and under diseased conditions. My own experience leads 
me to conclude that the touch is of more value than the sight, in 
intra-vesical diagnosis. 

When I eome to speak ol cystitis, the question of forming- an 
artificial fistula between the bladder and the vagina (kolpocystot- 
omy) for the purpose of diagnosis and for drainage will be con- 
sidered. 

HYSTERICAL ISCHURIA. 

I shall not detain you with any extended remarks upon the sub- 
ject of retention and suppression of the urine. There are several 
varieties of ischuria which take their name from 
the local seat and cause of the disorder. Thus 
we have the calculous ischuria, in which the disorder depends upon 
the presence of stone, either in the pelvis of the kidney, the ureter, 
the bladder, or the urethra; and the renal, the vesical, the ureteric* 
and the urethral, which are due to disease or obstruction in either 
of the parts just mentioned. All of these affections are as likely 
to occur in women as in men. 

But there is one form of ischuria, or of anuria, 

\ Ttericai may be which is almost entirely limited to women, and 

which is known as the hysterical ischuria. There 

are two reasons why this affection is called hysterical (1), because 



572 THE DISEASES OF WOMEN. 

it occurs in hysterical subjects, and is, therefore, of a nervous ori- 
gin; and (2) because it may attach itself to local lesions, more 
especially of the genito-urinary system, with which it has no 
necessary connection. 

Among nervous women it is not rare to meet with cases in 
which, apart from such mechanical causes as uteriue displacement, 
sub-involution, pelvic tumors, and the like, there is a great deal 
of disturbance of the renal function. There may be a deo-ree of 
suppression, with scanty urination, or perhaps, under strono- 
mental excitement, a total arrest of the function. You would be 
surprised to hear a patient say that she had not passed a drop ot 
water for two, three, or four clays and nights ; and possibly alarmed, 
if on percussion in the region of the bladder, you should fail to 
find any evidence of its distention, or on passing the catheter, you 
could not obtain more than a spoonful or two of urine. 

In this connection your knowledge of physiology will serve you 

a good purpose. You know that a sudden and complete arrest of 

the secretion of urine is a much more serious 

.eaTfons i0 in giCalCOmPli " affair > thai1 itS S radual a » d l™^ Suppression. 

And you also know that in the latter case there 
maybe an elimination of urea and other urinary elements from the 
gastro-enteric mucous membrane, which is compensatory. This 
explains the intractable vomiting or the diarrhoea which so often 
accompany hysterical ischuria. The fact that, in this affection, 
urea has been found in the matters vomited, and its proportion 
actually weighed from day to day, shows the clinical and necessary 
eonnection betAveen them. 

There is an essential difference between this form of ischuria 
and the suppression, with uraemia, which is incident to malignant 
jaundice ; between it and the uraemia with sepsis in certain puer- 
peral cases ; and between it and the urinaemia that is incident to 
ulceration of the bladder. 

In simple cases of hysterical retention of the urine the attack 
may be sudden and self-limited. This is the form 

iimLT PleCaSeSiSSelf " whichoften accompanies the hysterical parox- 
ysm, and which usually ends with a copious flow 
of clear, limpid urine. Such attacks are due to a temporary con- 
dition in which the renal sympathies are unhinged, and they sub- 
side when the cause is removed ; or, if they continue, may be cured 



HYSTERICAL ISCHURIA. 573 

by mental shock, by electricity, and by such traditional remedies 
and expedients as are useful in other forms of hysteria. 

If, however, this affection is associated with the graver forms of 

paralysis, and of renal or hepatic disease, the case is more serious, 

and we shall need to qualify our prognosis . 

The secondary form But, even in this secondary form the ischuria 

may sometimes be relieved by a few inhalations 

of chloroform, or of ether, by the passage of the catheter, as was 

advised by Dr. Wm. Hunter ; or by a peremptory refusal to use 

that instrument any longer, as in the following case, for the notes 

of which, I am indebted to our house physician, Dr. G. F. Shears: 

Case. — Miss A., aged 21 years, of a very nervous temperament 
was suffering with Bright's disease and from very painful men- 
struation. The act of urination was quite painful and often per- 
formed with difficulty. During one of my visits, the patient 
complained of great fullness in the bladder and of inability to 
pass the urine, although several efforts had been made. I used 
the catheter and left orders to be called if the urine was not 
passed in five or six hours. Promptly at the expiration of the 
six hours I was informed that she was in great pain and still un- 
able to urinate. The catheter was a^ain used, being passed with 
difficulty on account of the sensitive condition of the parts. 

Every remedy which seemed appropriate to this condition was 
tried, but without avail. The catheter was the only real means 
of relief, and, although its passage caused the most exquisite pain 
the patient begged for its use and it was applied four times a clay 
for ten clays before I determined that there was no real need of it. 
For some da} T s my suspicions had been aroused as I noticed- the 
varying character of the urine which was sometimes dark and 
scanty, sometimes nearly normal in appearance, and again as clear 
as the clearest spring water. Still I hesitated to act upon my 
suspicions. There was certainly a lesion of the uiinaiy apparatus 
and it appeared incredible that anyone would undergo the pain 
the patient seemed to suffer during the introduction of the instru- 
ment unless it was to relieve greater pain. 

At length being firmly impressed with the idea that the demand 
was hysterical, I determined to no longer use the catheter. At 
my next visit I succeeded in making the patient feel that the use 
of the catheter was very disagreeable to me, and that I considered 
it entirely unnecessary. These insinuations immediately brought 
tears and protestations against the injustice of my decision. I how- 
ever persisted in my idea, and told her that whatever it had done 
in the past it would not be necessary to use it again. My words 
were prophetic, tor although the case remained in my hands some 



.574 THE DISEASES OF WOMEN. 

four months longer, during which time the same symptoms were 
often present, the catheter was never again necessary. 

You are not to suppose that all of these cases are to be cured 
so promptly by the same, or by any other 
means. The best effects are often derived from 
fitly-chosen remedies, among which are apis mel., mere, cor., 
causticum, belladonna, hyoscyamus, and mix vomica. The most 
important clinical indications for these remedies will generally be 
found in the lesions of function or of structure upon which the 
ischuria is engrafted ; and you will therefore give due prominence 
to the coincident symptoms of cystitis, urethritis, nephritis, 
Bright's disease, and especially of neuralgia, hysteria, and spinal 
irritation. 



LECTURE XXXYI. 

CYSTITIS. 

■Cystitis. Causes. Symptoms. Diagnosis. Prognosis. Treatment, local, general, surgi- 
cal, and dietetic,— washing out the bladder,— remedies for— cystotomy, mode of per- 
forming, the after-treatment. Objections to, results of, the artificial eversion of the 
bladder, drainage.— i he milk diet in,— the Clysmic spring water in. The irritable 
bladder. Cave.— causes of, hysteria as a factor in, three points In the diagnosis of, treat- 
ment.— Stone in the bladder— diagnosis and treatment of. 

While all of the tissues of the female bladder may be the seat of 
inflammation, the mucous membrane is more prone to it than any 
other. It is the sub-aeute and chronic forms of mucous cystitis 
which are commonly known as catarrh of the bladder. Acute cys- 
titis is rarely an idiopathic affection ; and we do not very often 
meet with it unless in the puerperal state. 

Causes. — Cystitis may arise from exposure to cold and wet; 
from a direct extension of vaginitis and urethritis to the bladder ; 
from cliptheritis, from an excess of local treatment in uterine and 
urinary affections; from over-distention of the bladder; from the 
sudden arrest of leucorrhoeal and gonorrheal discharges; from 
prolonged retention and decomposition of the urine ; from falls and 
blows upon the pelvic region, and from the traumatism of natural 
or instrumental delivery; from the presence and pressure of 
abdominal tumors, or of the displaced uterus ; from foreign bodies 
that have been introduced into the bladder; from stone in the 
bladder, from polypus of the urethra, or from urethral calculus, 
carcinoma, or from haemorrhoids, as well as from ulcers, fissures, 
and foreign bodies in the rectum. 

Symptoms. — The symptoms which are most prominent, and 
which are always present in this disease, whatever its form or va- 
riety, are pain in the region of the bladder, vesical tenesmus, or 
strangury, and a frequent desire to urinate. The degree of the 
suffering varies with the acuteness and the severity of the attack. 
Most patients complain sorely of a feeling as if the bladder had 
not been quite emptied, and that they must continue to strain to 
accomplish it. They may even sit upon the vessel hours at a time. 

555 



576 THE DISEASES OF WOMEN. 

In the milder and more chronic cases the pain and tenesmus are 
very much aggravated by standing, riding, or walking about; 
while sitting or lying down may afford comparative ease. If, 
however, the constitutional symptoms are very marked, there may 
be a nightly aggravation which interferes with rest in the recum- 
bent posture. 

The urine is hot and highly colored, and in a little while be- 
comes alkaline in its reaction. At first it is cloudy, but soon con- 
tains mucus and blood; then it becomes more thick and glairy, and 
finally deposits a viscid, ropy, or purulent sediment. Its passage 
is often accompanied by pains which radiate along the ureters to- 
wards the kidneys, along the urethra down the lower extremities, 
toward the spine, the sacrum, or the perineum. If there is any 
considerable uterine disease or deviation, all the symptoms will be 
worse during the menstrual period. 

In chronic cases especially, the constitutional symptoms are such 
as indicate impoverishment of the blood from anaemia, and poison- 




Fig. 64. Ashton's fenestrated speculum. 

ing of it by the absorption of the urine, or of some of its elements 
from the ulcerated surface of the bladder. Urinaemia from this 
cause may be rapidly fatal, and is always accompanied by violent 
fever, vomiting, prostration, and collapse. 

Diagnosis. — Here, as elsewhere in the case of women, you should 
not depend exclusively upon the subjective signs in making the 
diagnosis. The symptoms I have just indicated are good enough 
so far as they go, but they are not sufficient. Nor w r ill the chem- 
ical reaction of the urine, or its microscopical examination settle 
the question, for these modes of enquiry are better suited to the 
diagnosis of renal than of vesical disorders. 

It is as impossible to make a careful and reliable diagnosis of 



cystitis. 577 

cystitis in women, without a physical examination by palpation, 
percussion, by the touch through the finger and the sound, as well 
as by the speculum , as it is in uterine disorders. And these means 
of differentiation are to be applied to the bladder in the same way 
that we apply them to the uterus and its appendages. The best 
speculum is Skene's endoscope (Fig. 60) although the local ex- 
amination of the meatus (Fig. 64) and the urethra from the vag- 
inal side may sometimes be advantageously made by an instru- 
ment like this, which is Ashton's fenestrated anal speculum. (See 
page 576.) 

I have sometimes used an intra-uterine speculum for the pur- 
pose of dilating the urethra and of inspecting its inner surface. 




Fig. 65. Intra-uterine speculum. 

The use ot the speculum or endoscope in these cases is some- 
times very important, for it may happen that an intractable cys- 
titis shall depend upon a fissure at the neck of the bladder, which 
could not be recognized except by actual visual inspection. 

Prognosis. — The prognosis depends upon the patient's general 
constitution, the curability of the complicating disorders, the grav- 
ity of the toxical symptoms, and the kind and duration of the treat- 
ment to which the patient has already been subjected. 

Treatment. — The treatment is local, general, surgical and die- 
tetic. In the acute form, local applications of hot water by means 
The local treatment, of compresses to the pubic region, poultices of 
flax-seed or of oat-meal, or warm sitz-baths are 
of the greatest service. Sometimes the hot- water irrigation of 
the vag-ina will mitigate the suffering and relieve the congestion. 
If the case is complicated with prolapse of the bladder, with dys- 
menorrhcea, or with pelvic congestion from any cause, the patient 
should be advised to lie with the hips elevated, and the shoulders 
depressed. In cystocele with cystitis, the bladder should be repos- 
ited and kept in place in order to prevent the decomposition of the 
urine. In case of stone, the foreign body should be removed. 

37 



578 



THE DISEASES OF WOMEtf. 



In chronic cases with copious discharges of mucus and pus, 
great relief may be obtained and a source of 



der. 



washing out the Mad- infection removed, by washing out the bladder 
once or twice daily with warm water. This 
may be done by means of a closely fitting syringe and a double- 




Fig. 66. Burns' reflux catheter and adjuster. 

current catheter, of which there are several on my desk. (See 
Figs. 66 and 67). 

A more convenient instrument for flushing the bladder, and for 




.Fig. 67. Nott's double-current catheter. 

medicating its inner surface afterwards, is such an one as this ? 
which was designed for intra-uterine purposes. 




Fig. 68. Molesworth's double canula and bulb syringe. 

Having cleansed the bladder it becomes a question whether you 

should medicate it topically. In cases with ulceration and the 

free secretion of a muco-purulent fluid, with 

Topical medication of the ^.j^ j haye certain l y ha d R00( ] effects 

from the local use of calendula. In rheumatic 
and hsemorrhoidal subjects you may substitute the hamamelis for 
calendula; while, if the trouble is of traumatic origin, arnica is 



The medical treat 
merit. 



CYSTITIS. 57fc 

best. Ill all cases, however, only a few drops of the strong tinc- 
ture should be added to the injection. 

The internal or general treatment, is sometimes very difficult 

and tedious. In the acute form, cantharis is more appropriate 

than any other single remedy. It is adapted to 

burning and tenesmus with violent pains in the 

bladder, the passage of scalding urine which 

issues drop by drop and is scanty, turbid, and sanguineous. When 

these symptoms are accompanied by prolapse of the uterus and of 

the rectum, with pains alonsf the ureters and in 

Cantharis 

the kidneys, with aggravation upon standing 
and relief from sitting, its effect is sometimes very prompt. The 
indication for cantharis is strengthened if the attack is due to a 
translation of gonorrhceal vaginitis or urethritis. And so like- 
wise of sub-acute cystitis which has resulted in atony of the blad- 
der with retention of urine. 

There is another indication for cantharis which it will be worth 
your while to remember, which is that it is adapted to cystitis 
occurring in those who are subject to erysipelas, more especially 
of the face and of the external genitals. It is just as true in the 
case of vulvar erysipelas, with vesical irritation, occurring in lit- 
tle girls, as it is with women. 

Belladonna is called for when the region ol the bladder is very 

sensitive to the touch, with shooting pains in 

the loins, and paralysis of the neck of the blad- 
der, with involuntary discharges of urine. It is especially adapted 
to those nervous and delicate subjects who cannot sleep, and who 
greatly exaggerate their suffering. In very acute cases, and 
especially if they are of gonorrhceal origin, a few powders of 
atropine 3, at hourly intervals will bring relief, and, if given 
early, will abort the attack. 

In chronic cases, cannabis sativa, chimaphilla, mercurius sol., 

copaiva, terebinth, hydrastis, causticum, pulsa- 

Other remedies. 

tilla, phosphoric acid, conium, dulcamara, lyco- 

podium, kali carb., and sulphur, have their special indications, for 

which I must refer you to the Materia Medica. 

Clinical indications. _-_ 1 „ ..,,..,. 

I he re are, however, a tew practical clinical in- 
dications which you may carry with you. 
For rheumatic cystitis, aconite. 



580 THE DISEASES OF WOMEN. 

For milky urine with a tendency to rapid decomposition, phos- 
phoric acid. 

For inflammation with paralysis of the bladder, hyoscyamus, 
causticum, carbo veg. s plumbum, or sulphur. 

For chronic cases complicated with peri-cystitis, colocynth and 
terebinth. 

For inflammation of the neck of the bladder especially, digitalis 
and elaterium. 

For catarrhal cystitis with a deposit resembling the white of an 
egg that is slightly cooked, dulcamara. 

For burning, pressure, and tenesmus, nux vomica, arsenicum, 
cantharis, or aconite. 

For intractable tenesmus, tarentula. 

For sub-acute cases induced by dampness and taking cold, dulca- 
mara. 

For chronic catarrhal cases, especially in old people, carbo veg., 
or cocculus. 

For cystitis arising from cantharides and other drugs, apis mel- 
lifica, or camphora. 

The surgical treatment consists in devising a means for the 
thorough and constant evacuation of the blad- 



Surgical treatment. 



l & 



der. There are two methods of filling this in- 
dication; (lj by the operation of cystotomy, and (2) by drainage 
through a self-retaining" catheter. 

The operation of cystotomy, or kolpocystotomy, is practiced by 
opening the bas-fond of the bladder and creat- 
ing a vesico-vaginal fistula, which establishes a 
continuous drainage of the organ. It consists in passing a grooved 
staff into the triangular space, the apex of which is at the com- 
mencement of the urethra and its base at a line drawn trans- 
versely from the orifice of one ureter to the other. While this is 
held firmly, the perineum being retracted with a Sims' speculum, 
and the patient anesthetized, an incision is made with a bistoury 
along the median line and in the groove of the staff. The edges 
of the wound are then seized with the forceps, everted, and about 
one-fourth of an inch of tissue on either side is snipped off with 
the scissors. The haemorrhage, which is not troublesome, if we 
have kept to the median line, may be controlled by torsion, by 
Pean's forceps, or by sef re-fines. 



CYSTITIS. 581 

In lieu of the incision, Dr. Pallen has proposed to make the 
opening with the thermo-cautery, which obviates the risk of 
venous haemorrhage, and prevents the premature contraction and 
closure of the fistula. 

The subsequent local treatment consists in washing out the 

bladder daily, and thoroughly, with starchy and demulcent fluids, 

such as flax-seed water, etc. When tne cystitis 

The after-treatment. . _ . . „ . . . -i-i't 

is cured, the artificial opening may be closed as 
in ordinary cases of vesico-vaginal fistula. 

The chief objections to this vesico-vaginal section are that the 
operation is not devoid of danger from consecutive cellulitis, for 

although in most cases at the point of the incision 

C yst^ e omy GStOVaffinal thevG ^ no cellular tissue between the vesical 
and the vaginal wall, still it may happen that 
there shall be, and that this tissue will become infiltrated and in- 
flamed in consequence of the wound, whether it is made by the 
knife or the cautery; that the relief from the pain of cystitis is 
substituted by a distressing infirmity which involves constant 
dribbling and escape of the urine as fast as it is poured into the 
bladder, and that the proportion of radical cures of cystitis in this 
way does not warrant a frequent resort to it. At the Woman's 
Hospital of New York, where the best operators, 
skilled nurses, and constant care were had, the 
following results were obtained : Cystotomy was performed for 
the relief of cystitis in seventeen cases, of which four were cured, 
and thirteen improved." * 

Simon practised a modification of vaginal cystotomy which was 

designed to invert the bladder and so to expose its internal surface 

that its lesions could be observed, and that tumors 

f T t h vflfH? aleversi0n which were beyond reach through the urethra 

of the bladder. J " 

could be easily removed. This plan consisted in 
making a T-shaped incision through the anterior vaginal wall , after 
which, and by means of tenacuke, the bladder could be turned 
inside out. The tumor being removed, and the exploration 
finished, the wound could be readily sewed up again. 

Where cases resist the ordinary treatment, or in conjunction 
with it, some sort of self-retaining catheter may be applied for 

* Diseases of the bladder and urethra in women, by Alex. J. C, Skene, M, D., etc., 1878, 
page 205. 



582 THE DISEASES OF WOMEN\ 




the purpose of keeping up a constant drainage of the inflamed 

organ. A bit of rubber tubing may be passed 

catheter.^ by ° so as to co ^ itself and be retained within the 

bladder, which, when it chokes with mucus can 

be cleansed by a syringe; or Holt's or Skene's self-retaining 

catheter may be left in situ for the 
same purpose. 

But you should not forget that, 

Fig. 69. Skene's self -retaining catheter, although the urine has free exit 

through the catheter, the bladder maybe partly filled meanwhile. 
So that, as Dr. Matthews Duncan says, " in order to insure that 
the evacuation is complete, you have to squeeze it out through 
the catheter, as the sportsman does with rabbits he has shot." 

There is no doubt in my own mind that, in cystitis, the regula- 
tion of the patient's diet is quite as important as it is in Bright's 
disease, or even in diabetes. I could cite several 
c Otitis 111111 dietlQ cases in my own experience in which this part 
of the treatment has clone more good than my 
remedies. I am confident that one of my patients, who had had 
cystitis for four years, owes her life to the milk diet; and that 
several others have been promptly and permanently benefitted by 
it. I began to use it in this class of cases five years ago (1875). 
and am fully prepared to recommend the plan adopted in England 
by Dr. George Johnson, who gives the following directions : 

" The milk may be taken cold or tepid, and not more than a 
pint at a time, lest a large mass of curd, difficult of digestion, form 
and collect in the stomach. Some adults will take as much as a 
gallon in the twenty-four hours. With some persons the milk is 
found to agree better after it has been boiled, and then taken 
either cold or tepid. If the milk be rich in cream, and it the 
cream disagree causing heartburn, headache, diarrhoea, or the symp- 
toms of dyspepsia, the cream may be partially removed by skim- 
ming. Constipation, which is one of the most frequent and 
troublesome results of an exclusively milk diet, is to some extent 
obviated by the cream in the unskimmed milk. When the vesical 
irritation and catarrh have passed awa} T , solid food may be com- 
bined with the milk, and a gradual return made to the ordinary 
diet." 

In some cases I have found that skim-milk, butter-milk, or 
koumyss answer very well. 

Another valuable, if not indispensable auxilliary in the treat- 



CYSTITIS. 583 

ment of sub-acute and chronic cystitis especially, is the use of 
appropriate mineral waters, the best of which, 
water S ySmlCSPrlDg J think, is the "Clysmic" spring water. My 
attention was first called to its value in conse- 
quence of its remarkable effect in the cure of one of my best per- 
sonal friends. 

The notes of her case, are as follows : 

Case. — Mrs. , aged 26, the mother of three children, had 

suffered for four years from what was diagnosticated to be " ca- 
tarrh of the bladder," " inflammation of the neck of the bladder," 
and "the first stage of Bright's disease with malarial fever in 
its worst form." So many different opinions as to the nature of 
the disease were given by Drs. Alonzo Clark, George E. Belcher, 
and several other distinguished and competent physicians of New 
York City. Both schools of treatment were faithfully and 'skil- 
fully tried, but without avail. The catheter was used for many 
weeks; then an injection of morphine, and twice each week an 
application of iron was made to the interior of the bladder, which 
was continued for six months. It became impossible for her to 
walk, for the slightest exertion caused an untold agony with local 
spasms that required the use of seven grain suppositories of opium 
before they would yield. The pain that was caused by the desire 
to urinate was beyond description. 

When her weight had been reduced from 172 to 112 pounds, 
and it seemed impossible that she should recover, a final consulta- 
tion, of physicians was held and it was decided to wash out the 
bladder and inject a solution of the nitrate of silver. The prog- 
nosis given was that she must die, or be bed-ridden for the balance 
of her life. 

Before beginning the use of the caustic injections she began to 
drink the "Clysmic" water. In a very little while the painful 
symptoms subsided, and in a few weeks she had entirely recovered 
her health. More than two years have now elapsed, and there 
has been no return of the difficulty. 

This kind of spring water seems especially adapted to those cases 
of urinary disorder in women, which are catarrhal in character, 
and which are compounded with miasmatic and dyspeptic derange- 
ments. For this reason it has a wide range of application in 
paludal districts, and with those patients who have developed a 
kind of urinary cachexia, which does not respond to ordinary 
remedies, and which, except for its use are exceedingly difficult of 
cure. 



584 THE DISEASES OF WOMEN. 



THE IRRITABLE BLADDER. 

A bout fifty years ago the celebrated Dr. Kobert Gooch first 
recognized what he afterwards described as the 'irritable uterus.' 
In our day, with improved methods of physical examination, we 
identify most of the symptoms of that peculiar affection as belong- 
ing in reality to what is called the irritable bladder. Here is a 
case of this very common and intractable disorder. 

Case. — Mrs. , aged 22, has been married four years, but has 

had no children and no miscarriages. Her menstruation is nor- 
mal in the quantity and character of the flow, and also in the regu- 
larity of its recurrence; but for a week before her period, and 
durinff it until the flow has ceased, she suffers a marked ag-o-rava- 
tion other urinary symptoms. These symptoms consist chiefly of 
a desire to urinate, and of dysuria. She must void her urine at 
intervals of from ten to thirty minutes; the periods varying with 
exercise while upon her feet, with the return of the catamenia, 
with loss of sleep, and with mental worry. The more frequent 
the discharge the more cloudy the urine. She has been for eleven 
months past in the care of a gynaecologist of this city who has 
cauterized the cervix uteri every week. 

A local examination revealed a condition of the os and cervix 
uteri that was normal except for the effects of the cauterization. 
The sound showed that the uterus was slightly anti -flexed. The 
bladder, as felt at the anterior cul-de-sac, and by conjoined 
manipulation was not hypertrophied or especially sensitive. The 
urethra and the meatus were normal. 

A second local examination, which was made two days in ad- 
vance of the monthly flow, disclosed the same conditions, except 
that the forward flexure of the uterus was somewhat increased. 

The treatment consisted in repositing the uterus, and enjoining 
a strict monthly quarantine, with rest upon the back, beginning 
four days before the flow, and continuing until it had ceased. 
The womb was replaced four times in all by 1he sound; she took 
no medicine, and in two months was entirely relieved. 

This case illustrates the fact that ante-flexion of the uterus may 

provoke an irritation of the bladder. Other deviations of the 

uterus may have the same effect. And so like- 
Causes of. J 

wise may an excessive use of the speculum, of 
caustics, or of the catheter, too frequent coitus, prolapse of the 
vagina, vaginitis, urethretis, nephritis, stone in the bladder, can- 
cer, haemorrhoids, hVsure in ano, a lack of cleanliness, errors in 
diet, and the abuse of diuretics. 



STONE IN THE BLADDER. 585 

Other causes are oxaluria, or the deposit of the oxalate of lime 
in the urine; and uric and phosphatic deposits, which earthy mat- 
ters are direct sources of irritation to the vesical mucous membrane. 
This affection is very common in gouty subjects. 

In a considerable share of cases this disorder is a hysterical neu- 
rosis. When it is so there is very likely to be either an incouti- 
Hysteria as a fac- neiice or a retention of the urine at times, and 
tor in. other syptoms of hysteria also will be present. 

For the irritable bladder is not a disease per se, but a symptom, or 
condition, which must depend either upon a local or a general cause. 
By exclusion, if you know what these causes are, you will be able 
to differentiate between them, and to settle upon the proper one. 

The healthy bladder is not tender. If, upon passing the vesical 

sound, and pressing lightly while the instrument is within, much 

r™. ■ •*'.'.. pain is felt, it is a case of inflammation and not 

Three points in the L 

diasnosis of. one of simple irritation of the organ. If the 

-depth of the bladder, when measured from the meatus to the 
fundus, is more than five inches, the probabilities are that we 
have a case ot irritable bladder. Moreover, if the bladder is 
always irritated and excited to contraction by the presence of the 
urine, whether that fluid is cloudy or limpid, the case is of nerv- 
ous origin, and the irritability depends upon vesical hyperses 
thesia. 

If we know the cause and can unravel the complications, the 
treatment of the irritable bladder is not difficult. Manifestly no 

Treatment single remedy or expedient is sufficient for all 

cases. Apis mellifica, mercurius, hyoscyamus, 
belladonna, lycopodium, ignatia, nux vomica, ferrum, and thlaspi 
bursa, have each been extolled, and are useful under appropriate 
indications. When the gouty and lithic acid diatheses are present, 
lithia carb. is an excellent remedy. For irritating urinary deposits 
nitric, or the nitro-muriatic acid, with plenty of fresh water, or 
the "Clysmic" spring water for drink. 

STONE IN THE BLADDER AND IN THE URETHRA. 

In the treatment of vesical diseases you will often suspect the 
presence of calculi, and it is therefore important that you should 
know something of this subject. For, while stone in the blad- 



586 " THE DISEASES OF WOMEN. 

der is much less frequent with women than with men, it is an 
Relative frequency affection that sometimes gives us a great deal 
of, in women. of trouble. The short and dilatable urethra in 

women not only favors the escape of such small foreign bodies as 
by incrustation would otherwise become larger and more trouble- 
some, but it also facilitates their surgical removal per vias natu- 
rales. 

In addition to the ordinary causes of stone in the bladder, which 
are applicable to men and women alike, this affection is rendered 
Causes more frequent in those women who have under- 

gone the operation for vesico-vaginalhstula, and 
in those who are suffering from cystocele. 

The symptoms are those which I have just enumerated when 
speaking of cystitis, viz. : pain, dysuria, vesical tenesmus, increased 
Symptoms upon standing or walking, and the presence in 

the urine of mucus, pus, and blood, the morbid 
products varying with the duration and severity of the accompa- 
nying inflammation. 

Physical examination by the passage of the sound, by the con- 
joined use of the sound in the bladder and the finger in the vagina, 
or by the passage of the index linger directly into the bladder, i& 
not difficult, but is very decisive. The calculus that escapes de- 
tection in this way must be encysted, but even in that case it may 
be found by first distending the bladder with warm water, and 
then making the examination. In some cases the urethral specu- 
lum may be of service by bringing the foreign body directly into 
view. (Fig. 61.) When the calculus has been forced into the 
urethra it is readily recognized by the touch, applied to the vagi- 
nal surface of that canal, and also by the introduction of the sound. 
If the calculus has lodged in the ureter, or even in the pelvis of 
the kidney, its presence may be detected by Simon's method of 
catheterizing those tubes, as I have already explained. (Fig. 62.) 

The prognosis depends upon our ability to remove the foreign 
body with certainty and safety; upon the curability of the co-ex- 
isting inflammation and ulceration ; and upon 

Prognosis. ° m 3 *■ 

the tendency of the disease to relapse. 
The indications for treatment are few and simple. If the calcu- 
lus is already in the urethra we have only to dilate the passage, to 
seize the stone with a pair of forceps, to give it a slight rotary 



STONE IN THE BLADDER, ETC. 587 

motion, and to extract it. If it is still in the bladder, and we are 

satisfied that its diameter does not exceed an 

Treatment. inch? the urethra s i 10U id b e dilated, and it 

should be carefully seized with the forceps, so as not to include 
the vesical wall, and then delivered slowly through that canal. 

When the stone is too large to be extracted through the 

urethra, one of two methods for its removal may be adopted : (1) 

Lithotripsy and it may be crushed by the lithotriptor, and the 

vaginal cystotomy, bladder carefully washed of the fragments, or 
(2) the operation of vaginal cystotomy, which I have already des- 
cribed, and which opens the way for its removal through an incision 
in the vesico-vaginal septum, may be made. If the first of these is 
determined upon, care must be taken not to wound the inner 
surface of the bladder, and not to permit any of the fragments to 
remain as the nucleus for a new formation ; and if the second is 
necessary, the wound will need to be sewed up, as in vesico-vagi- 
nal fistula. The possibility of vaginal cystotomy in women does 
away with the necessity for the resort to the perineal section, 
which has been the usual mode of operation in men. 

In case of vesical calculus occurring in a patient with occlusion 
of the vagina, disease of the uterine cervix, anchorage of the 

supra-pubic litnot- uterus, or intra-pelvic tumors of such a nature as 
omy - to interfere with a resort to vaginal cystotomy, 

we should have a resource in supra-pubic lithotomy. This opera- 
tion which has been so skilfully and successfully practised by my 
good friend Prof. Helmuth, of New York, * is quite as available 
in women as in men; but it should be restricted to those cases in 
which the vaginal incision is impracticable. 

Sometimes these calculi are voided spontaneously; sometimes 
their passage may be facilitated by the resort to warm sitz-baths, 

spontaneons dis- ot by irrigation of the vagina or the rectum with 
charge of. } lot wa t er ; and sometimes they are forced through 

the urethra by straining while the patient is in an unnatural posi- 
tion, as in bending very far forward, or while lying down. A little 
while ago this specimen was given me by a private patient who 
had passed it voluntarily. Her history is as follows : 

Case. — Mrs. , seventy-three years of age had been subject to 

* The American Observer, Nov. 1880, page 532. 



588 THE DISEASES OF WOSIEN. 

attacks of renal colic. They seemed to be induced by fatigue, she 
had had them for two years, and they were relieved by the usual 
remedies. In the last but one of these paroxysms, the suffering 
was located in the left ureter exclusively, and the relief, when it 
came, was sudden and complete. She then passed five weeks with 
greater ease and comfort than she had known in the two years. 
At the end of that time, after several severe fits of straining to 
urinate, she succeeded in passing this calculus. It is one inch in 
length, and moulded into the form of a cylinder. Its weight is 
thirty-six and one-half grains. 

SARCOMATOUS GROWTHS WITHIN THE BLADDER. 

The occurrence of these and of papillary growths within the 
bladder are rare. The following is the most remarkable case of 
the kind that I have seen: 

Case. — Mrs. , age 37, has for several years suffered from a 

burning during urination, and a spasm of the neck of the bladder 
after passing the first few drops of water. The urine is strong 
with a heavy sediment. A year ago it became bloody and now the 
loss of blood is sometimes frightful. When the bladder is irrigated 
small bits of flesh and clots sometimes come away. There is a 
stinging as of fine needles in the bladder, with a sense of retrac- 
tion in that organ on drinking cold water. Straining to force the 
flow of urine fails of effect, but a deep inspiration causes it to flow 
freely. There is a monthly aggravation with tympanitis and invet- 
erate insomnia. 

Failing to detect a stone, and confident of some local cause for 
the hemorrhage, I dilated the urethra, and, on passing the index 
finger into the bladder, discovered a growth as large as a lemon. 
This was removed without accident and was found to be sarcoma- 
tous. Seven months later the old symptoms had returned and the 
bladder was found to be studded with small friable growths which 
were removed with the curette. In six months more a third crop 
was taken for the relief of symptoms that were worse in every way. 
She developed a wretched cachexia, became exhausted and emaci- 
ated, and in a few months died. 

The use of the curette within the diseased bladder is a danger- 
ous expedient, and, although it is somewhat painful, should be 
done without an anaesthetic, lest the bladder might be perforated. 



LECTURE XXXVII. 

UTEKINE DEVIATIONS AND DISPLACEMENTS. 

Uterine Deviations and Displacements. General considerations upon. The natural position 
and mobility of the uterus. The uterine ligaments and the cellular tissue as a means 
of support. The etiology of uterine displacements. The predisposing, and avoidable 
causes of. The intrinsic and extrinsic and the accidental ditto. The symptoms of. The 
diagnosis of. The treatment. The scope and value of internal remedies exclusively— 
the necessity for reliable indications of all kinds. The cardinal symptoms in the choice 
of a remedy. Case.— The use and abuse of pessaries. Reasons for objections to them. 
Harmful varieties of. Contra-indications for. Indications for. Not incompatable with 
our remedies. Abdominal belts and supporters. Arguments pro and con. Dr. Hodge's 
experience with them. 

No single subject in the realm of gynaecolgy has attracted so 

much attention as the question of uterine displacements and their 

relation to uterine pathology. There has been, 

tio G n S neraiCOnSidera " and sti11 is ' a class of Physicians who regard 
disorders of place as the essential and funda- 
mental element in uterine pathology, and who refer all, or nearly 
all, the diseases of women to this single cause. The great leaders 
in this party were, the late Dr. Hodge, of Philadelphia, and Dr. 
Grailly Hewitt, of London. But, as with the theories of so many 
others, their exclusive views have been modified, and uterine 
deviations are now taking their proper place among the causes, 
effects, and complications of pelvic disorders. 

Before we proceed to the study of the separate displacements, I 

must speak of the normal position of the uterus, and of its range 

of mobility within the limits of health. For, 

rZt-m^T'Z™* having heard so much of uterine deviations and 

mobility of the uterus. *= 

of their evil consequences, you may have fancied 
that the uterus is held in a fixed position, like the articulating 
surfaces of a joint. The fact is that the womb is more movable, 
and in a healthy way, than any other organ in the body, not even 
excepting the eye. In a qualified sense it is never at home. In 

foetal life and until puberty, it is an abdominal 

toJ^&T ^**" ^g* 11 '' du ™£ the menstrual life it belongs 
within the pelvis ; in the early months of preg- 
nancy it lies below the superior strait; in the latter half above it; 



590 



THE DISEASES OF WOMEN. 



in puerperality it is first an abdominal, and then pelvic again. 
These changes of place are physiological and necessary. 
■ But more than this, it is so mobile as to be constantly changing 
its position, although in a slighter degree. Talking, breathing, 
swallowing, coughing, sneezing, moving an arm or even a finder, 
standing, walking, lying down, the effort at stool and at urination, 
the monthly engorgement of the uterus, and many other such slight 
causes may move it in different directions and alter its position 
with reference to the fixed parts of the lower pelvis. So that, there 




A clinical rule. 



Fig. 70. Normal position of the womb. 1. Kectum. 2. Uterus. 3. Bladder. 4. Vagina. 

are slight and self-limited forms of uterine deviation which are ol 
no consequence in a clinical point of view, except 
in establishing the rule that uterine displace- 
ments are important and mischievous only when they are -permanent , 
and when they create or complicate disease by their effects upon the 
uterus and upon other organs within the pelvis. 

This diagram (Fig. 70) will give you a correct idea of the 
normal position of the uterus as it lies between the bladder in 
front and the rectum behind. Observe that even with the bladder 
distended, its axis inclines forward at an obtuse angle with the 
axis of the vagina; and that its fundus and body are raised above 
the bladder in such a way as greatly to be influenced by its vary- 
ing form. This fact, together with the intimate union existing 



UTERINE DEVIATIONS AND DISPLACEMENTS. 591 

between the lower segment of the uterus and that of the bladder, 
shows why one of these organs cannot be displaced without in- 
volving the other. 

The uterus is sustained by folds of the peritoneum with inter- 
lacing fibres and areolar cellular tissue. The utero-vesical lio-a- 
ments in front of the womb, the utero-sacral 

The uterine iiga- Wments behind it, and the broad ligaments on 

ments. ... . . . 

either side of it, are the moorings by which it is 
attached. Below, its only support is derived from the vaginal 
column, which rests upon the perineum. 

Etiology. — The causes of uterine displacement are predisposing 
-and exciting. Among the former the most prominent is preg- 
nancy, which, by increasing the size and weight 

Predisposing causes. „ < ? „ , °. 

oi the uterus; by changing its iorm and its 
vascularity as well as its relation to other organs; by straining its 
ligaments and demoralizing its means of support; by debilitating 
the general strength and tone of the nervous and muscular sys- 
tems; and by the traumatism that is incident to delivery, is a 
more potent factor of these difficulties than any other. 

Menstruation is also a powerful predisponant of uterine displacer 
ments.* The monthly congestion of the ovaries and their append- 
ages, the risks of interruption to the flow, the sudden diversion of 
the blood to other parts of the body, and the pelvic engorgement 
that attends upon an imperfect or incomplete performance of this 
function, supply the conditions for disorders of place which are 
unknown before puberty and after the climacteric. Obstinate and 
habitual constipation, paralysis of the rectum, and a round and 
capacious pelvic brim should also be classed among the predis- 
ponents of uterine displacements. 

Another class of predisposing causes are avoidable, and must be 

charged to the usages of modern society. The habit of tight lacing, 

the wearing of heavy skirts and dresses which are 

Avoidable causes. „ . , ,, , 

not properly suspended from the shoulders, and 
of high heeled shoes, which change the relation of the organs 
within the pelvis and place the centre of gravity where it does not 
belong, are all of them, in a greater or less degree mischievous. 
Skating, dancing, riding on horseback, without regard to the 
menstrual period, and especially the new method of cultivating 

*See pages 132 and 160. 



582 THE DISEASES OF WOMEN. 

the voice, which is called the " abdominal method" and which 
develops the diaphragmatic, at the expense of the thoracic respira- 
tion, are fruitful sources of uterine displacement. 

The exciting causes of this class of troubles are of three kinds, 
(1) the intrinsic, or those which lie within the uterus itself; (2) 
the extrinsic, or those which are within the 
pelvis and abdomen but outside the uterus ; and 
(3) the accidental, or such as result from some mechanical vio- 
lence. 

The most frequent of the intrinsic causes of uterine displace- 
ments of all kinds are puerperal subinvolution, pregnancy, chronic 
metritis, menorrhagia, interstitial and intra- 

The intrinsic causes. . - ^ . i i • -ii-i,-i 

uterine growths, as fibroids, polypi and hydatids ; 
hypertrophy of the cervix ; and chronic corporeal cervicitis. The 
study of these causes is indispensable to their careful and successful 
treatment. I would no more think of trying to cure a chronic case 
of prolapsus without first measuring the depth of the uterus with 
a graduated sound like this, (Fig. 71) than I would of giving 




Fig. 71. Jenks' elastic graduated sound. 

a diagnosis of whooping cough without looking at the frsenuni 
linguae. 

When you have no graduated one, an ordinary sound will 
answer the purpose. Each and all of the affeetions named are 
characterized by an increased depth of the uterus, when we meas- 
ure from the os to the fundus of the organ. For this reason, the 
sound is as important in a case of prolapsus or of procidentia, 
as it is in versions and flexions of the womb, although in a very 
different way. 

The extrinsic causes are the inclination or bias which the uterus 

has received during pregnancy; the pressure of extra-uterine 

fibroids, of ovarian, abdominal, and pelvic tu- 

The extrinsic causes. ^^ ^ Qf ^ abdominal viscera ; t he lesions 

of place that have been entailed from pelvi-peritonitis, pelvic 
cellulitis, and pelvic hematocele ; ascites, chronic cystitis, cysto- 
cele and stone in the bladder; rectocele, haemorrhoids, prolapse 



UTERINE DEVIATIONS AND DISPLACEMENTS. 



593 



of the bowel and of the vagina, and laceration of the perineum. 

The kind and degree of displacement induced by this class of 

causes varies with circumstances and with the tolerance which 

the uterus has for them. 

The accidental causes are chiefly mechanical, and 

include the mischievous effects of falls, blows, and 
injuries from jumping, or straining 
the body severely. The extreme 



The accidental causes. 



or spasmodic action of the diaphragm in 



coug- 



hing, 



convulsions, in running, or rapid breathing from any 
other cause, may also put the womb out of place. 
Here we have a veritable dislocation, which is the 
result of applied force, the same as in luxations of 
the elbow or shoulder from an accident. 

Symptoms. — The symptoms are direct or pelvic, and 
remote or reflex. The direct symptoms are recogniz- 
able by one or another of the modes of physical ex- 
ploration of which I have already spoken. (Lectures 
IV and V.) They vary with the kind and degree of 
the displacement, and will therefore be treated of 
when we come to speak of the several varieties of this 
general disorder. 

The remote symptoms are of two kinds (1) those 
which arise from a derangement of the intra-pelvic 
circulation, and (2) those which depend upon disorders 
of the nervous system, both ganglionic and cerebro- 
spinal. The former class of causes accounts for most 
of the troubles with the liver, the kidneys, and the 
digestive organs which either as cause or effect, usu- 
ally attend upon uterine displacements. The nervous 
causes implicate the more distant functions and or- 
gans, and indirectly give rise to the hysterical symp- 
toms which are so common in these disorders of place, FlG 
as well as in uterine affections generally. 

Diagnosis. — The diagnosis will be considered when we come to 
speak of the different varieties of displacement to which the uterus 
is subject. At present it must suffice to say that a careful and 
reliable diagnosis in this class of affections is absolutely impossible 
without a physical examination. 



72. Gid- 
den's uterine 
sound. 



594 THE DISEASES OF WOMEN, 

Treatment. — The general therapeutics of uterine displacements 

involves several important questions: (1) the significance and 

clinical value of the subjective symptoms in the 

General therapeu- ch ice f th reaiedv or rem edies to be em- 

tics of. " ' 

ployed; (2) the possibility of curing these 
displacements with internal remedies only; and (3) the use and 
abuse of the mechanical treatment by pessaries of various kinds. 

Concerning the two first of these inquiries, it has always seemed 

to me that, in a given case, if the subjective symptoms are common 

. , to two or more kinds of uterine deviations ; if 

The scope and value ' 

of internal remedies they are not to be depended upon exclusively, 
exclusively. even in the simplest cases, in making a diagnosis ; 

if the misplaced womb may cause such derangement of the circu- 
lation and of innervation as will persist until the organ is reposited 
and kept in situ ; if the lesions of the uterus and of its appendages, 
which cause and complicate these displacements, are of so varied 
a character ; and if the hysterical epi-phenomena are most prom- 
inent and least significant, we ought not to rely wholly upon the 
complaints of the patient in our selection of the remedy. You may 
depend upon it that the cures which have been claimed for internal 
treatment based upon such indications merely, are faulty and 
fallacious. 

The idea is not that the symptoms of which the patient 
complains in these cases are of no value, neither that remedies 

The necessity for re- which are g iven u P on pathogenetic indications 
liable indications of an are always inefficient. For these subjective 
symptoms have their value, which varies in dif- 
ferent cases; and medicines that are given in this way are some- 
times, but not certainly, or even usually, curative. Both are too 
slender to be relied upon exclusively. Both need to be re-enforced ; 
the symptoms, by a careful physical and objective examination, and 
by physiological reasoning; and the indications, by a knowledge 
of the intrinsic, the extrinsic, and the accidental causes of the dis- 
placement, by clinical experience, and by physiological reasoning 
also. Hence I have said that the reports of cases in which it has 
been claimed that deviations and displacements of the womb are 
easily cured by the affiliated remed}^ are faulty, because they have 
not told the whole story ; and fallacious , because they may mislead 
you into supposing that such a result is the rule and not the excep- 
tion. 



UTERINE DEVIATIONS AND DISPLACEMENTS. 



595 



That our internal remedies may, and do sometimes work won- 
ders in this way, even in this class of cases, there is no doubt, in 
my own mind at least, for I have tested them very thoroughly. 
But I should lose faith in my own clinical convictions, if they had 
no better foundation than the improved state of feeling, and the 
mere say-so of my patients. 

In an old play, I think it is the Octoroon, there is a scene in 
which a poor fellow is on trial for his life for having murdered a 
man in an out-of-the-way place. The evidence is all in, and the 
case is about to be closed with the result of liberating the prisoner, 
when a travelling daguerreotypist rushes into court with a pic- 
ture that he had incidentally taken of the scene of the murder, 
including, of course, the portraits of the prisoner and of his victim. 
When all other evidence had failed, the guilty man was convicted 
by this proof and by the plea of this providential witness who in 
referring to his camera-obscura, said "the apparatus can't lie!" 

In all semi-surgical affections like those under consideration, the 
subjective sensations partake of the nature of circumstantial evi- 
dence. Without more direct and positive proof we shall first fail 
to convict the patient of having a real displacement, and after- 
wards to convince a competent professional jury that we have 
really cured one. But, when the evidence that the uterine sound 
can furnish is brought into court, we shall have the facts in the 
case, for " the apparatus can't lie." 

Bear in mind, therefore, that the symptoms upon which you are 
to rely for the choice of your remedies in this class of cases are the 
cardinal signs that are coupled with some struc- 
tom h s eCardinalSymP " tural or functional disorder of the generative 
intestine, the bladder, or the rectum, or of the 
peritoneum, or the cellular tissue within the pelvis. If either of 
these lesions is post-puerperal, or if it is especially connected with 
menstruation, the symptoms will have a peculiar significance. 

You will have an ample illustration of this mode of prescribing 
in my clinic, but let me quote a case which several of the sub- 
classes have seen upon my table : 

Case. — Prolapsus from sub-involution. Mrs. T , aged 28, 

married, has had but one child which is now two years old, and no 
miscarriages. Her labor lasted only half an hour, her lying-in 
was tedious, but so far as we can learn, she had no especial illness. 
Her health has, however, been wretched from that time until the 



596 THE DISEASES OF WOMEN. 

present. She nursed the baby for fourteen months. The menses; 
returned when the child was nine months old, and have come 
regularly and copiously every three to four weeks since that time. 
She complains sorely of bearing down pains, and dragging in the 
hips and loins, which almost entirely prevents her from being upon 
her feet. At times there is so much downward pressure that she 
feels as if all the pelvic organs would be forced out. Her appetite 
is gone, and she is generally in a very forlorn condition. 

Local examination by the touch, found the uterus considerably 
prolapsed, tumefied, and tender. In the field of the speculum, the 
os uteri was found to be lacerated in a linear direction, and the 
anterior lip discolored and badly swollen. The sound passed readily 
and showed that the depth of the uterus was four and one-half 
inches. 

She took secale cornutum 2, three times a day for two weeks; 
and then secale 3, as often for another fortnight. She received no 
local treatment whatever, and took no other remedy. 

At the end of one month the uterus was measured again in the 
presence of the sub-class, and its depth was found to have been 
reduced to three and one-half inches. Meanwhile her general 
health and spirits had improved in a corresponding degree. The 
dilapidated, dragging sensations had almost entirely disappeared, 
the pressure was gone, and the appetite had returned. She had 
passed through another menstrual period, but instead-of continu- 
ing copiously for five or six days, as heretofore, it lasted only three 
days and was of moderate quantity. Secale 3, was continued as 
before. 

I will not repeat what has already been said concerning subinvo- 
lution of the uterus, but will remind you that, in the case just cited, 
the cause of the prolapsus, as well as of the menorrhagia, was recog- 
nized by physical exploration. The curative indications were partly 
physiological, and partly clinical. If the secale would finish the 
work of uterine involution, which for some unknown reason had 
been interrupted during the lying-in, it was exactly what was 
needed to put an end to the prolapsus. That it did so, even after 
an interval of two years from her lying-in, was evident to all the 
pupils and several physicians who saw the case with me. " It runs 
without saying" that the laceration of the cervix was not an 
obstacle to the cure of the subinvolution. 

The opposition to the use of pessaries is not 

The opposition to pes- f there have alwa g been thoge who were 

saries an old story. . . . 

so prejudiced against them that they could not 
be persuaded to employ them. This is one of those questions, 
which like the propriety of tying the funis, of putting on the 



UTERINE DEVIATIONS AND DISPLACEMENTS. 



597 



The causes of mis- 
chief from pessaries. 



"binder, or of giving quinine tor intermittent fever, blooms peren- 
nially in our medical societies. Nor is it likely to be settled until 
physicians have learned to discriminate between cases of displace- 
ment that are primary and those which are secondary. This is the 
.first step towards the correction of extreme views on both sides; 
for where both parties hold to a half-truth neither has the benefit 
of the whole truth. 

A pessary is a crutch, or a prop, that is used under protest, and 
for the most part temporarily. If it is of 
the proper kind, and is properly applied, in 
suitable cases only, it is 
an undoubted means of 
relief. The mischief that 
is sometimes done by them arises from the 
notion that they are always necessary ; from 
a preference for one pattern for all cases 
indiscriminately; from their not being fitted 
appropriately ; from their being introduced 
or worn without regard to the month; and 
from a lack of cleanliness, which is often 
consequent upon wearing them. Certain 
varieties are especially harmful. If the ring 
pessary (Fig. 30) is too large it will stretch 
and paralyze the vaginal muscular fibre, 
and practically destroy the means of uterine Fig. 73. Mcintosh's pessary, 
support from below the organ. If the cervix is capped with a 
cup that is either too large or too small, its protecting epithelium 

will soon be destroyed, and 
abrasion and ulceration will fol- 
low. All kinds of stem-sup- 
ports are likely to induce cellu- 
litis, or peritonitis which may 

Fig. 74. Curved stem pessaries. result fatallv. (Tii?. 74.) 

When pessaries have been worn long enough to have been forgot- 
ten, and have decomposed or broken within the vagina, they 
have given rise to ulceration and to fistulas. A case of this kind was 
reported to our National Society a few years ago by my friend Dr. 
S. S. Lungren, of Toledo, in which he found the fragments of a 
fiflass tumbler that had been introduced bottom side up to sustain 





598 



THE DISEASES OF WOMEX, 



the uterus. Similar cases are on record in our medical works,, 
and, although it may seem strange to you that a woman should 

have forgotten the introduction of such 
an instrument, you may perhaps stumble 
upon such things in your own exper- 
ience. A case is recorded in the Ohio 
Medical and Surgical Journal for 1852, 
in which a wooden pessary was removed 
after it had been forty-one years in the 
vagina. 

The contra-indications for pessaries are 
numerous and important. They are cer- 
tain to be harmful if 

Contra-indications t j . sub-involution 

for. 

of the uterus, chronic 
metritis, corporeal cervicitis, endo-cervi- 
citis, in vaginitis, and in all kinds of 
circum-uterine inflammation, as pelvic cel- 
lulitis, and pelvic peritonitis with or with- 
out hematocele. 

penary!"' McIntosh ' s uterine They are more especially indicated in 
displacements with vaginal relaxation and prolapse, procidentia, 
with cystocele and rectocele oc- 
curring in wo- 

Indications for. ' p 

men of a very 
lax fibre, with muscular atony, 
who have borne their children rap- 
idly, and who are compelled to be 
upon their feet most of the time. 
In some cases of uterine displace- 
ment that occur in the early 
months of pregnancy, and in scir- 
rhus of the cervix and lower 

segment of the ! 

womb, pessaries 
are of great temporary benefit. 
The same is true when, as in old fio. 16. Coxeter stem pessary, 
ladies, we are not warranted in operating for the radical cure of 
these displacements. 




Case. 







UTERINE DEVIATIONS AND DISPLACEMNTS. 



599 



Briefly, I think it is wrong to abuse these instruments, or to 
insist upon dispensing with them altogether, until we have some- 
thing better to fill their place and to answer 
^Argument for their ^©ir purpose. If you discard them entirely, 
and refuse to apply them under any condition, 
a certain share of your patients will be compelled to consult those 
who will use them for their relief. And, after all, since they do 
not interfere with the action of fitly-chosen remedies, we may 
resort to them as to any other form of surgical dressing, as for 
example, to a truss in hernia, or to splints and bandages in other 
dislocations. 

Closely related to the last of the three questions that we have 

answered is that of resorting to external, or abdominal supports 

for the relief of certain forms of uterine displace- 

^Abdominal suppor- ments> There are twQ sid(?s tQ tMs quest i on a l so . 

The objections urged against these belts, binders 
or corsets, as a class are that, when snngly applied they weaken 





Fig. 77. Mathieu's abdominal supporter. 

the abdominal muscles by their steady pressure; that they force 

the intestines downwards upon the displaced uterus and thus 

increase the difficulty ; that they interfere with 

the freedom of action of the diaphragm, and so 

embarrass respiration; and that, sooner than with any other form 



600 



THE DISEASES OF WOMEN. 



Advantages of. 




of support, a woman becomes a slave to them, and must continue 

to wear them indefinitely. 

The advantages of this form of support are their cheapness, the 

ease of their application by the patients themselves; the possibility 
of wearing them and the relief afforded by them 
in some cases of peri-uterine inflammation ; their 

adaptation to cases in which from over-distention and rapid child- 
bearing the abdominal parietes 
are so lax as to permit the 
weight of the intestines to fall 
upon the uterus; and the tact 
that, when properly arranged, 
they afford a better perineal 
support than any form of pes- 
sary can possibly do. 
fig. 78. But these instruments are not 

adapted to all cases indiscriminately; nor is any one pattern 

always suited to the same variety of 

displacement in different persons. 

One woman will feel more comfort- 
able, and derive greater benefit from 

a simple elastic belt which she can fit 

for herself, while another will need a 

more complicated binder with elastic 

straps and adjustable pads, which can be shifted like those upon 

a truss. Here are three kinds of belts which in many cases will 

answer a good purpose. (Figs. 78, 79 and 80.) 

Other forms of this binder are more or less popular in different 

parts of the country. You will find a dozen or more of them on 

my desk, and can examine them, or try them on if you like, at the 

close of my lecture. 

Twenty years ago one who had had more experience than any 

other physician in America, in the treatment of uterine displace- 
ments wrote as follows: 

" From what has been said, the conclusion may fairly be made, 
that external supports are at least but palliative as regards some 
symptoms of displacement, and that they have no tendency to 
restore the organ to its prope 1 * position; but, on the contrary, 
that the whole tendency of the abdominal brace is to aggravate 
the pressure on the uterus, and increase its deviations. Hence 




Fjg. 79. 



UTERINE DEVIATIONS AND DISPLACEMENTS. 



601 



such supporters should be enumerated among the causes, original 
or aggravating, of uterine displacements, and not among the 
remedies. This view is confirmed by the constant experience of 
the author. Few patients, for some years, have come under his 
care in which these bandages have not been used for a longer or 
shorter time ; yet, in all cases, the displacement was found still 
existing, and in some to a great degree." * 





Fig. 80 a. 

Shannon Self Adjusting Supporter. 



Fig. 80 b. 
Shannon Elastic Supporter. 



It is well to remember that women with downward displacements 
of the womb are really suffering from a hernia of that organ, and 
like one with an inguinal or a femoral hernia, are in need of some 
kind of a mechanical support. For those women who are obliged 
to be upon their feet a great deal under these circumstances, one 
of the two forms of the Shannon supporter often answers a very 
good purpose. ( See Fig. 80. ) 

*On Diseases peculiar to women, including displacements of the uterus. By Hugh L. 
Hodge, M. D., etc., 1860, page 299. 



LECTURE XXXVIII. 



PROLAPSUS UTERI AND PROCIDENTIA. 

Pseudo-prolapse of the uterus. Prolapsus uteri, with superficial ulceration of the cer- 
vix. Prolapsus uteri with right latero- version. Prolapsus with anterior inclination 
of the fundus uteri. Procidentia uteri. Procidentia uteri from pertussis. 

Case. — At five p. m., of June 4, 1866, I was summoned in haste 

to visit Mrs. , who, the husband wrote me, was "almost dead 

with prolapse of the womb." In his note he requested me to 
bring the necessary instruments for replacing that organ. The 
patient, aged 52, had been ill one week, under the care of two 
physicians who had diagnosticated the case as one ot prolapsus 
uteri, and who, I was told, had several times restored the womb 
to its normal position. These operations had caused her great 
pain, and she had a mortal dread lest 1 should think it necessary 
to repeat them. The day previous, the doctor had succeeded in 
introducing a Hodge's lever pessary, which, after a little, dropped 
out of itself. Although she had taken opiates freely and fre- 
quently, she had not slept for two days and nights. There was 
retching and bilious vomiting, and, although she had taken cathar- 
tics, the bowels had not been opened for four days. There was 
much ineffectual tenesmus, and with each effort at stool she com- 
plained of feeling as if the uterus and neighboring organs would 
be expelled from the body. She was exceedingly nervous, and at 
intervals of five to fifteen minutes suffered acute pains across the 
inferior portion of the abdomen. These pains were aggravated 
by motion and by any considerable degree of mental excitement. 
She described them a. short, sharp, spasmodic, cutting and col- 
icky in nature. She was greatly depressed in spirits — "must 
have relief or she should die." 

I enjoined rest, as first and most important. Belladonna 3d, 
and nux vomica 3d, were to be taken in hourly alternation until 
the symptoms improved, after which they were to be repeated 
every two hours. If she slept, she was not to be awakened or 
disturbed. If the bowels did not move before daylight, they 
might give her an enema of tepid water. I made no examination 
per vaginam. 

June 5, 5 :30 p. m. — Patient better. After taking the first dose 
of the belladonna she slept for some minutes, and had but one 
more spasm of the pain. The remedies were repeated only at 

602 



PROLAPSUS UTERI AND PROCIDENTIA. 605 

long intervals, for she slept quietly during the greater part of the 
night. At daylight, not having had a stool, the enema was ad- 
ministered with good effect, although the passage was very pain- 
ful, and she was much exhausted in consequence. The tenesmus 
and vomiting were relieved, and she declared herself well. Con- 
tinued the same remedies once in four hours. The " touch" re- 
vealed the uterus in situ. The husband and family were delighted 
with the promptness of the relief afforded. 

Two days later this patient was able to attend to her household 
duties. 

Nothing is more common than a temporary prolapse ot the 

womb. Some women have it at each menstrual period; others 

after any extraordinary fatigue, as in walking 

prolapse. 11070 ' merine or ridin g '> some from [L fit of meiltal anxiety or 
of coughing; others after a stool; and others 
again after coitus. When induced by these causes it is a sell- 
limited affection, and may pass away with rest in the recumbent 
posture. This is a very different thing* from a chronic and invet- 
erate prolapse, and requires very different treatment. If my 
predecessors had recognized this fact, this patient would have 
improved before I came ; for in that case they would have for- 
borne to do anything mischievous. A correct knowledge of 
special pathology on the part of the physician is sometimes an 
excellent safeguard for the patient. 

One of two ill results may follow a wrong diagnosis in cases of 

this kind. Either the slight and temporary displacement may be 

converted into a permanent one, with all its 

Consequences of in- - . -it-it /» 

correct diagnosis. consequent suffering and disorder, by reason or 

a harsh and inappropriate treatment; or it may 

happen that harmless and inefficient means may get the credit of 

holding some specific curative relation to uterine deviations of 

whatever kind. 
Nothing could be more cruel, harmful and unnecessary, than to 
resort to manual treatment in such a case as 

laUo n n neCeS ' arymaniPU " this ' hl the Sta # e in wMch l f0Ulld it: - Wh y 

explore and worry such a sensitive womb with 
the sound? Probing will not relieve these acute symptoms, and 
a pessary would be about as useful as a fracture box in inflamma- 
tory rheumatism. 

Opiates might deaden the sensibilities, but they are possessed 



€04 THE DISEASES OF WOMEN. 

of no curative relation to the symptoms detailed, and would indi- 
rectly unhinge the nervous sympathies more 

Harmful medicat,on. ° , . . , , , 

and more. 11 the cathartics operated at all, 
the effect would be, by increasing the peristaltic action of the in- 
testines, to increase the uterine displacement and to render it 
more permanent. There is no question, in my own mind at least, 
that very many examples of confirmed prolapsus have been en- 
tailed upon our patients by such inappropriate and inexcusable 
treatment at the hands of those who have preceded us. 

On the other hand, the fact that such cases may get well of 
themselves, providing we do nothing to interfere therewith, is 

too frequently lost sight of by our physicians. 

and P quackishclim3? Evei ^ khld ° f vemed Y haS thus been £ iven aAld 

extolled as a specific for uterine deviations. 
You will find the most incredible stories of cures with this or 
that dilution detailed in our books and journals. Perhaps a 
single dose has worked the most marvelous results, the womb 
being replaced, according to the report, almost as soon as the 
medicine was swallowed, no allowance being made for the tend- 
ency to a spontaneous reduction of the dislocation, the self-lim- 
ited nature of the attack, or the good effect of rest in the proper 
position. 

When carefully chosen, it is reasonable to suppose that our 
remedies are capable, in many instances, of curing what might 

otherwise develop into a troublesome case of 
what remedies may llter i ne p ro lapse. We may sometimes avert 

do in prolapsus. L l J 

such a consequence of neglect, or of ill-treat- 
ment, in much the same manner as we prevent a case of pulmon- 
ary congestion from resulting in pneumonia. It is possible, by 
this means, to spare our patients much suffering, and frequently 
to turn aside what would otherwise be a real calamity. I cannot 
claim that belladonna is a specific for any form of uterine luxa- 
tion, but I may insist that it was adapted to the relief of the 
peculiar incidental symptoms of which this patient complained. 
Nux vomica will not go to work like an intelligent agent to re- 
store the fallen womb to its proper position, but it holds a spe- 
cific, pathogenetic relation to the incidental symptoms in many 
cases of the kind. And so of podophyllin, sepia, calcarea carb., 
and many other remedies. W^e must select the remedy according 



PROLAPSUS UTERI WITH ULCERATION. (505 

to the symptoms that are present, just as in a case oi incipient 
pneumonia, or pleurisy. In this stage, the proper treatment is 
medical, and not surgical. 

Whether you should alternate remedies, as it seemed best for 
me to do in this case, your own observation must help you to de- 
cide. It would be very wrong to claim that 

dits kerriati0n0lreme cures have D0t been effected in this manner, 
and equally at variance with truth, to assert 
that careful study and close observation do not lead a majority of 
practitioners more and more to prefer the single remedy. 

PROLAPSUS UTERI, WITH SUPERFICIAL ULCERATION OF THE CERVIX. 

Case. — Mrs. , aged twenty-four, began to menstruate at 

twelve, from which period she dates her illness. The catamenia 
are irregular, sometimes appearing once in three weeks, again in 
four, and, occasionally, with an interval of five weeks. The only 
particular suffering experienced at the period is a dull, aching 
pain about and in front of the left hip, and a dragging pain 
across the loins. The flow usually continues three days, and is 
normal in quantity and quality. 

During the inter-menstrual period she complains of a bearing 
down sensation within the pelvis. There is great weakness of 
the back in the lumbar and sacral regions. Standing for any 
length of time, or walking a short distance, fatigues her exceed- 
ingly. When weary, she is subject to a peculiar sensation in the 
lumbar region, "as if a considerable portion of the backbone, 
perhaps six inches long had been removed." This is soon followed 
by a faint feeling, and sometimes by actual syncope. At other 
times, and especially if she is in a room in which there are many 
other persons, as in a church, or in a concert hall, there is a sense 
of impending suffocation. Sometimes the unnatural feeling along 
the spine recurs without any apparent cause or premonition. 
Then follows an irresistible propensity "to drop down upon the 
knees." At such times the lower limbs feel numb, insensible, and 
semi-paralyzed, but the knees are especially weak and powerless. 

Another symptom which she has remarked is a sense of coldness 
on the top of the head, which, whenever she swallows either cold 
or warm drinks, is curiously changed into a sensation as of "crawl- 
ing" under the scalp. So marked is this symptom that she has 
insensibly acquired the habit of placing her hand on that part of 
the head for its relief, whenever she nuts a cup or glass to her lips. 

For some years past (she does not know how long) she has had 
leucorrhcea. The discharge is habitually more profuse immediately 
before, but ceases during menstruation. In character she de- 
scribes it as "catarrhal," creamy, bland and unirritating. 



60() THE DISEASES OF WOMEN. 

The touch reveals the uterus prolapsed, the neck of the womb 
tender and tumefied. When she stands, the anterior lip of the 
cervix rests upon tiie posterior vaginal wall, directly over the 
perineum. Upon examination with the speculum, a large, irreg- 
ular, suppurating ulcer was found to extend within the external 
os uteri, and over a considerable portion of the anterior lip of the 
cervix. 

Uterine deviations not unirequently date from puberty. They 
are the more likely to follow if menstruation begins at a very early 

uterine luxations or a very late age. With this patient the flow 
may begin at puberty. fi rs t appeared when she was but twelve years 
old. Under these circumstances it must have required more than 
ordinary effort on the part of the ovaries and the generative intes- 
tine to establish this very important function. The ripening, 
transit, and parturition of the ovum in such subjects resembles 
labor, and so far as disorders of place are concerned, the conse- 
quences to the uterus are of a similar character to those which are 
contingent upon that process in older women. In the case before 
you, the afflux of blood to the internal generative organs, the 
increased weight of the womb, the requisite dilatation and relax- 
ation of the uterine cervix and of the vagina, the contractile effort 
of the womb to expel its contents, supplied the identical conditions 
which predispose to uterine displacements following abortion or 
labor at term. 

Irregular menstruation may be a cause or a consequence of uter- 
ine deviations. In one form or another they are very apt to co- 
exist. It is unusual to meet with a chronic case 

Irregular menstru- 
ation a cause of prc-iay- of prolapsus, or of retro-version, in which the 

menses are not more or less irregular as to the 
time and method of their recurrence. This state of things is 
undoubtedly due to a derangement in the local, intra-pelvic circu- 
lation. The uterus has become the seat of venous engorgement. 
Its increased weight has borne it down upon the structures that 
were designed to sustain it, until they have given way, and it has 
become displaced. For if the uterine ligaments are not fortified 
against this increase of weight in the womb, an undue or unus- 
ual determination of blood to this organ, or sluggishness in its 
circulation, weakens these supports, and renders them more liable 
to yield. 



PROLAPSUS UTERI WITH ULCERATION. 607 

Hence, also, the frequent complications of uterine displacements 
with chronic disorders of digestion. The connection between the 

uterine luxations venous systems of the uterus and the liver, 
•and digestive disorders, explained in my remarks upon another case is 
significant. There are few examples of prolapsus which are not 
accompanied by haemorrhoids, prolapse of the rectum, or by a more 
or less obstinate constipation. 

Lumbar and sacral pains are incident to most cases of prolapsus, 
and of uterine ulceration also. But the kind and degree of these 

Lumbar and sacrai pains are modified according to circumstances. 
P ains - As a rule, they are more acute and tormenting 

in nervous, hysterical, and delicate women than in those who are 
of a different temperament and organization. Among the more 
robust and energetic there is sometimes a remarkable tolerance ol 
uterine displacements, which may exist for years with little com- 
plaint of pain in the loins, or of especial suffering of any kind. 
But these cases are exceptional. 

In prolapsus, the pains in the lumbar and sacral regions are 
brought on or increased by standing, riding or walking, and some- 
times by bending forwards and then rising suddenly to an upright 
position. The back feels very weak, and perhaps as though it 
were actually broken in two. The more chronic the case, the 
greater the suffering, more especially if at the same time the 
patient has leucorrhcea, irregular menstruation, or ulceration of 
the uterine cervix. For, independently of the falling of the womb, 
these several diseases are almost always accompanied by similar 
symptoms. This poor woman has them all, and it is by no means 
strange that such an array of symptoms should present themselves. 

The dropping down of the uterus, and its direct pressure upon 
the anterior sacral nerves, and also upon the utero-cervical ganglia, 

Proiapus and par- °f tne sympathetic, is sufficient to account for 
-aiysis the sudden, partial, and temporary paraplegia, 

or powerlessness in the lower limbs. She falls upon the knees 
irresistibly. There is numbness and semi-paralysis, which are 
self-limited. The nervous currents between the spinal center and 
these parts are interrupted , and the consequence is manifest. Rest, 
with change from the upright to the horizontal position, causes 
the Avomb to lift itself, as the French would say, and the normal 
nervous circulation returns. 



608 THE DISEASES OF WOMEN. 

The same physiological reasons explain the peculiar sensation 
"as if a portion of the spine had been removed," the fain tness, the 

Hysterical compii- syncope, and the eccentric symptoms which are 
cations, referred to the top of the head. Through the 

frequent recurrence of this displacement, the nervous system has 
acquired a predisposition to hysterical complications. On this 
theory, the increase of suffering from swallowing cold or warm 
drinks, which act produces a "crawling" sensation beneath the 
scalp, as well as the sense of suffocation when in a room full of 
people, are by no means inexplicable. The relief afforded by 
pressure upon the top of the head, proves that the peculiar sensa- 
tion felt in that region is purely nervous. 

Let me remind you, however, that these symptoms are none the 
less real because we style them "nervous," and because it is only 
The reality of k * ner- through our knowledge of the reflex nervous 
vous' symptoms. system that we are competent to explain their 
existence. In truth, this woman has suffered more from these 
peculiar sensations in the head than from pains in the loins, or in 
the left iliac region, the temporary paralysis, or from any and all 
of her other symptoms. For, although the element of exaggera- 
tion enters largely into the hysterical constitution; we cannot 
doubt that persons with this temperament are possessed of an 
increased susceptibility to pain and disease, and that they do really 
suffer more than others under similar external circumstances. 

But this case has other complications. Some authors will tell 
you that prolapsus, leucorrhoea, and uterine ulceration, like a 

symptoms versus cough or a diarrhoea, are not to be considered as 
disease, so may separate disorders, but as symptoms: 

merely. And in the main their view is correct ; but symptoms, 
like quarrels, do not come wichout cause. When it is possible* 
we muse find out their source, in order to be able to explain their 
significance and to cure them. There may have been an order of 
sequence in the coming on of these symptoms, which it is most 
desirable and necessary for the physician to know. 

Our patient has a chronic prolapse of the womb, which in all 
. probability owes its origin to causes already 

Leucorrhoea and ul- l J < » J 

ceration from proiap- named. Following this displacement, and con- 
sus * sequent upon it, she also has leucorrhcea and 

uterine ulceration. Which of these two contingent affections came 



PROLAPSUS UTERI WITH ULCERATION. 609 

first, we do not know. Nothing is more common than a leucor- 
rhceal flow of a catarrhal nature accompanying the slighter and 
more temporary degrees of uterine prolapse. Here the discharge 
depends on glandular derangement without structural lesion. 
There need be, and generally is, in these cases, no ulceration what- 
ever. 

But if the uterine deviation is persistent, and especially if the 
uterus lies low upon the perineum, its friction against the poste- 
rior vaginal wall is pretty certain, sooner or 

Ulceration from , . . , . „ .. 

abrasion. later, to cause an abrasion ot its investing epi_ 

thelium. This mechanical cause may induce and 
perpetuate a superficial ulceration of the neck of the womb, or of 
the vagina, or of both of these parts together. As the deeper 
seated textures become involved in the lesion, a more or less copi- 
ous discharge is poured out, and in future the leucorrhcea will 
either depend entirely on, or be greatly modified by the existing 
ulceration. 

The belief is very general that, directly or indirectly, all cases 

of uterine ulceration originate in the inflammatory process. But 

I apprehend this view is not correct. Inflam- 

ulceration sans ma tion always imperils the proper nutrition of 

inflammation. . . . . 

the organ or tissue in which it is seated. Its 
chief danger lies in this very fact. But there are many disorders 
of nutrition, and some of them of a most serious character, which 
certainly are not in any manner dependent upon the inflammatory 
process. 

It is probable that a large proportion of cases of uterine ulcer- 
ation commence with simple abrasion of the mucous surface. The 

wearing of an ill-adjusted pessary, or of one 
ADrasion° f uterme w T hich is made of improper material, the careless 

employment of the female syringe ; the abuse of 
sexual intercourse; horseback riding; mechanical injury of the 
os uteri during delivery ; the use of harmful injections thrown into 
the vagina, especially after coitus or during menstruation; the 
contact of corrosive discharges from the uterine cervix, and of 
vitiated semen, as well as friction from the various uterine dis- 
placements, may be sufficient to produce it. 

Superficial ulceration of the os following abrasion of its epithe- 
lium differs from other varieties of uterine ulceration. It consists 

39 



610 THE DISEASES OF WOMEN. 

essentially in defective reparation of its investing membrane, and 
Nature of ulceration not in a destructive metamorphosis of the un- 
from abrasion. derlying textures. 

Treatment. — The medical management of such cases as this is 
especially vexatious. We must begin rightly or we shall fail. 

Any attempt to cure the leucorrhcea without 
^ Therapeutical reflec- ^cogmzmg or relieving the ulceration of the os 

uteri, or to remedy this lesion without doing 
anything for the displacement of the womb, would reflect upon 
our skill and experience. And so also if we were to elevate some 
of the incidental, irrelevant, hysterical symptoms of which our 
patient complains, to the dignity of characteristic symptoms, when 
they do not deserve such distinction, and afterwards busy our- 
selves with curing them. 

It is a rule in therapeutics that the symptoms of a complicated, 
chronic case of disease should be made to disappear in an order 

which is the reverse of that in which they came 

Rule Reducible from __ the j t fi t d SQ b fe t th starting 

the order of symptoms. ' « 

point. But when applied to the treatment of 
uterine affections, this rule has many exceptions. The most 
stupid blunders have sometimes been perpetrated through ignor- 
ance of this fact. 

The first indication is to keep this woman as quiet as possible. 
She need not lie in bed all the time, but she should assume the 

recumbent position either upon the side or the 

Postural treatment. * ; . , , 

back. And, if necessary, she should persevere 
in this tor some weeks, or even for months. For you will not 
cure these cases so promptly as some enthusiasts would lead you 
to believe possible. Walking, standing, and sitting aggravate her 
sufferings. She must therefore, keep quiet. 

Her shopping and her church-going must be done by proxy. 

She is no more able to run a sewing machine than she is to run 

with a fire engine. And, if she were my pri- 

Dressinsthe hair, etc. Jr . . , 

vate patient, I should forbid her dressing her 

own hair — which is really one of the most tiresome and injurious 

kinds of exercise for a woman who is suffering" from uterine dis- 
cs 

ease. Her clothing should be worn loosely about the waist. 

No matter what the kind and degree of the uterine displace- 
ment, if the os uteri is abraded or ulcerated, it is wrong to apply 



PROLAPSUS UTERI WITH ULCERATION. 611 

any pessary whatever; lor, by direct pressure upon, and contact 

with, the denuded surface, these instruments 

contra-indications n W ork serious mischief. Under such circum- 

for the pessary. J 

stances, they have been known to increase the 
sufferings, to extend the lesion of the cervix, to multiply the reflex 
symptoms, and to augment the leucorrhceal flow. Keeping- the 
patient in the proper position is a harmless and efficient substitute 
for these appliances in all cases of this partiuclar kind. (Exit the 
patient.) 

Another requisite for this woman's recovery, of which I have 
forborne to speak in her presence, is the prohibition of sexual con- 
gress. Otherwise it is next to impossible to 

Prohibition of sexual e f ^ ^^ jj sepamtion from 

congress. t L 

her husband will insure against the undue 
determination of blood to the internal generative organs, which 
is consequent upon the sexual act, and will thereby remove one 
of the principal causes that serve to perpetuate the abnormal con- 
dition and position of the womb. If we overlook or ignore this 
item, a cause which may counterbalance all our efforts at cure, 
will be constantly at work, and we may fail in consequence. 

I do not doubt that much of the boasted efficacy of escharotics 
in uterine ulceration should really be attributed to the interrup- 
tion of sexual intercourse, which they necessitate. I can conceive 
that frequently the caustic might be less harmful than coitus. 
„ , ,. „ And so, also, of similar cures which are ascribed 

Modus operandi of ' ' 

caustics, etc., in cer- to the use of cold water in the various hydro- 
tam cases. pathic establishments. Without saying a word 

against this system of treatment, it is quite probable that the ben- 
efit derived in many ol these cases is due as much to the enforced 
absence of the patient from the bed and board of her husband, as 
to the bath and remedies that are prescribed. 

For the cure of a simple, suppurating ulcer of the os uteri, I 

know of nothing so beneficial locally as the calendula. To a 

drachm of the strong tincture of calendula add 

Calendula topically. , 

two ounces each ot glycerine and distilled water. 
Of this mixture a tablespoonful may be put into a teacupful of 
tepid water for an injection per vaginam. This injection, which 
should be retained as long as possible, may be repeated once or 
twice daily. The calendula not only heals the abraded surface 



612 THE DISEASES OF WOMEN. 

most kindly, but it also relieves the swelling and tenderness of 
the cervix, which are so marked in the case under review. In not 
a few instances it may suffice to arrest the leucorrhceal flow. 

Or a mixture of glycerine and water in equal parts may be 
applied by means of cotton tampon. If you think best, there 
is no valid objection to adding a few drops of 
en?s herl ° Cal eXPedi " the gratis to this preparation. I have some- 
times melted simple cerate and applied it directly 
to the denuded cervix, through the speculum, by means of a 
camel's hair pencil. Injections of sugar and water are wonderfully 
efficacious in healing these simple abrasions of the utero-vaofinal 
mucous membrane. The preparation of collodion with castor oil, 
recently extolled by M. Latour, in his method of treating diseases 
by isolation, has been of great service to some of my private patients, 
in whose cases it was applied to the os uteri, in the manner as- 
recommended for the simple cerate. 

The internal remedies most appropriate for the case under con- 
sideration are nux vomica and calcarea carbonica. I need not 
detail their respective indications. If you will study the symp- 
toms carefully, excluding those which are merely sensational and 
incidental, you will not fail to endorse my prescription. They 
should be given, for a limited period, night and morning — the nux 
at night and the calcarea in the morning. Let her report at the 
end of a week. 

PROLAPSUS UTERI WITH RIGHT LATERO-VERSION. 

Case. — Mrs. — complains of a series of symptoms, from which 
she says she has suffered for more than a year past. She is mar- 
ried, but has never borne any children, neither has she ever had 
a miscarriage. She has dragging pain in the hips and loins, and 
sometimes there is strangury, with obstinate constipation. The 
bowels move at long intervals spontaneously, but with much effort 
and tenesmus, which at times are ineffectual. The stools are in- 
variable dry, hard, and scybalous. When straining at stool, she 
sometimes " feels as if everything would be forced from her." 
All the unpleasant symptoms are increased during and tor some 
time after the menstrual period. At times she experiences severe 
cramping pains in the right thigh, which come on suddenly after 
prolonged exercise upon her feet, or after standing for a consider- 
able time. The only means of relief that she has found trom the 
latter paroxysms is obtained by lying down immediately upon the 



PROLAPSUS UTERI AVITH RIGHT L AT ERO- VERSION. 613 

left or opposite side of the body. By keeping quiet in this posi- 
tion for a little while, the cramp-like pain subsides and soon leaves 
entirely. She has not been able to lie with any degree of com- 
fort upon her right side since her ill-health began. And if she 
rolls upon that side while sleeping, the cramps in the right thigh 
will awaken her at once. She has , an almost constant headache 
in the region of the temples. During and after the menses, how- 
ever, it is apt to be located in the occipital region. The now is 
too profuse. It continues a whole week, instead of four days as 
heretofore. It is also too frequent, returning as often as every 
three weeks at the farthest. 

You have doubtless observed the relative frequency of consti- 
pation as an attendant upon the diseases of women. One of its 
most common causes is a paralysis of the rec- 
constipation from t j j^ exam j ne a this patient per vagi- 

rectal paralysis. l . & 

nam, and found the uterus prolapsed, and at 
the same time lying obliquely from right to left across the vagina. 
The most plausible theory of this displacement is that the descent 
and pressure of the womb against the bowel caused it to become 
paralyzed. The accumulation of faecal matter in the rectum 
forced the fundus of the uterus toward the right acetabulum, 
and lateio-version was the natural and necessary consequence. 
Whether the constipation really preceded or followed the pro- 
lapsus, it would be impossible to say. Latero-version of the 
uterus always depends upon pressure applied to the side of its 
body or fundus. It is incident to the history of fibroids, ovarian 
tumors, and to tumors within the broad ligaments. When due 

to either of these diseases the organ may be 
,n^ at r°.r^n,T displaced either toward the right or the left 

an over-loaded rectum. 1 _ o 

side of the pelvis. When, however, it depends 
upon the pressure of a tumor caused by impacted faeces contained 
within the rectum, the fundus will, as in the case before us, always 
be thrown toward the right acetabulum and the cervix toward 
the tuberosity of the left ischium. The diagnosis may be con- 
firmed by the introduction of the uterine sound or probe. 

The incidental symptoms are interesting and significant. The 
cramping pains of which Mrs. complains are referable to 

pressure of the corpus uteri upon the anterior 

The cramping pains. , - A 

branches ot the sacral nerves, W hen sue lies 
upon the right side, the womb falls upon those nerves, or is 



614 THE DISEASES OF WOMEN. 

pressed by the distended rectum against them. When she turns 
upon the left side, it drops away, and the cramp ceases. When 
she walks too far, or is upon her feet for too long a time, the 
womb is more decidedly prolapsed. The nearer its approach to 
the perineum the more direct and positive the pressure of the 
rectum toward the right side of the pelvis. Straining at stool 
only increases the difficulty, and it is no marvel that she feels as 
if all the pelvic organs would be forced through the vulva. 

These cramp-like pains are very similar to those which may 
attend upon an advanced stage of labor. In presentations of the 
vertex especially, when rotation occurs suddenly and the head 
passes rapidly through the inferior pelvic strait, direct pressure 
upon the sacral nerves often causes the patient to cry out that 
her " legs are cramping." And so also in cases in which the 
womb is retroverted suddenly, as from a fall or other impulse, 
one or both the lower extremities may be violently cramped and 
even paralyzed. In this poor woman's case there is no dropsy of 
the feet and ankles, and the veins are not varicose, because the 
pressure is not applied to the vessels going to the lower extremi- 
ties. Those vessels emerge from the superior pelvis beneath 
Poupart's ligament, and are, therefore, not liable to be pressed 
upon by the uterus, excepting in its gravid state, after the fourth 
month. 

One of two causes may be sufficient to account for the implica- 
tion of the bladder in this case. The strangury might be caused 
by the displacement of the uterine cervix, or 

The vesical symptoms. ,, , 

by pressure of the uterus against the neck of 
the bladder and the urethra. The uterine cervix is so joined with 
the inferior portion of the bladder that it cannot be very decid- 
edly displaced without dragging upon that organ, and give rise 
to more or less of irritation, inflammation, and vesical tenesmus. 
Hence it sometimes happens that the most prominent and per- 
sistent symptoms of uterine luxation are referred almost exclu- 
sively to the bladder. And, because they suppose that all de- 
rangements of the urinary function are due to renal disorder, 
patients not imfrequently consult their physician for the cure of 
disease of the kidneys, when they are really sufFering from some 
form of displacement of the womb. 

Such slight degrees of prolapsus, as are incident to the men- 



PROLAPSUS WITH RIGHT LATEKO-VERSIOX. 615 

strual period and to the early weeks of pregnancy, are sometimes 
the cause of frequent and painful micturition. These sufferings 
are, however, relieved spontaneously — by the escape of the menses 
and the subsidence of the monthly hyperemia in the one case, 
and by the final ascent of the uterus above the superior strait in 
tfie other. In chronic prolapsus all these symptoms are made to 
Vanish, at least temporarily, by lifting the womb into its proper 
position. 

This case illustrates the possibility of uterine displacements 
disconnected with abortion or with labor at term. The frequent 
return of menstruation, and the excess of the flow, indicate a 
primary disorder of this very important function. 

Treatment. — There are two reasons why this woman is not 
well. The first is, that her rectum is paralyzed ; 

Leading indications. *■ u 

the second, that she menstruates too freely and 
frequently. All the symptoms that have the least significance 
may be referred to one of these two causes. 

This is the most common form of constipation in females. If 

the muscular coat of the rectum has lost its tonicity through 

neglect of the patient to attend to the calls of 

To remedy the con- n;l t U re, or to go to stool regularly everyday, 

stipation. ' c c J J J ' 

' this bad habit should be corrected. Enemata 
containing olive oil, or castor oil, may be given for temporary 
relief, with the view of softening and removing the impacted 
faeces. Laxative food is of more service in constipation depend- 
ing upon causes which affect the upper portion of the intestine. 
Some of these patients with paralysis of the rectum might eat 
brown-bread, oatmeal, figs, prunes, or baked apples until dooms- 
day without the least benefit. 

If the uterus is prolapsed, or so displaced as to press directly 
against the rectum, that pressure must be removed, or the con- 
stipation can not be cured. And since these causes act and 
react, the uterine deviation may depend upon 

Empty the rectum- th j k f ^flfe™ in the rec tum, the pres- 

restore the uterus. J ' l 

ence of faecal matter within the gut, or upon 
straining at stool. Pessaries are contra-indicated in case of 
uterine displacement with profuse and too frequent menstrua- 
tion. 
The most ordinary remedies for this variety of constipation, 



616 Tin: diseases or women. 

with its incidental uterine displacement, are alumina, mix vom- 
ica, natrum mur., plumbum, opium, belladonna, sulphur, zincum 
and lycopodium. 

Among those which are in best repute for the cure of too fre- 
quent and copious menstruation you will find calcarea carb., 
china, phosphoric acid, cantharis, zincum met., spongia, sulphur, 
kreosotum, and magnesia carbonica. 

This patient will take mix vomica 3d at night, and calcarea 
carb. 3d in the morning, one dose of each daily. She must keep 
off her feet as much as possible, particularly at the catamenjal 
season. 

PROLAPSUS WITH ANTERIOR INCLINATION OF THE FUNDUS UTERI. 

Case. — Mrs. S , aged 27 years, has never been pregnant. 

She has had prolapsus and has worn a ring pessary for a year past. 
Local examination discloses a downward displacement, with a 
slight inclination of the fundus of the uterus towards the bladder. 
The menses are regular, but the prolapsus is much ivorse during 
the flow. The bowels are constipated and relaxed alternately, but 
she has no haemorrhoids. Nux vomica 3, three times daily. 

This case proves the possible inefficiency of the ring pessary, 
but it does not argue that vaginal supports are never necessary or 
useful. If the ring had been removed in advance of 
the menstrual period, and replaced after it, some good 
miofht have resulted. But, awkward as it is, I think 
a Hodge's pessary (Fig. 83) would have done better. 
For some of these cases the dumb-bell pessary known 
as Trask's (Fig. 81), or the hard-rubber pessary de- 
vised by Dr. Fraser (Fig. 84) will keep the organ in 
place. Zwanke's butterfly pessary, which is very 
popular in Germany, is sometimes very useful in 
these cases. As a rule, Hornby's instrument, which 
is cheap, durable, easily adjusted, with a spring-stem, and a per- 
ineal support, is the one that I prefer. 

PROCIDENTIA UTERI. 

Case. — Mrs. , aged forty-seven, who comes before the sub- 
clinic to-day has suffered from procidentia uteri for nineteen years, 
and since the birth of her first child. She has since that time, 
given birth to five children and had one miscarriage. The menses 




PROCIDENTIA UTERI. 



617 





congestion 



its 
the same 



ceased two years ago, and she now complains of a feeling of great 
weakness, especially in her limbs, while the womb is dislocated, 
and asks that something may be done for her # 

A fortnight ago I showed you a patient who 
had suffered from procidentia of the uterus, 
for sixteen years. You will 
remember that in her case, 
the tumor was very large, and that she told 
us it had been carried externally lor a num- 
ber of years without being" replaced. The sur- pig.82. zwanke's pessary. 
face of the tumor was excoriated in large patches, and the cervix 
was swollen and discolored almost beyond recognition. The 
tumor was the form and size of an ego-- 
plant, and, from venous 
lower portion had very much 
color. (Fig, 88.) 

In the case which is now on the table, 
although the tumor is not so lar^e, the 
fig. 83. Bodge's pessary, extrusion of the womb at the vulva is 
equally manifest. The pear-shaped outline of the organ is pre- 
served, there are no excoriations, the two lips of the cervix are 
recognizable, you can see the patulous os, 
and the parts are not so discolored as in 
the former case. The exemption from 
some of these lesions is easily explained, 
for this tumor can be readily reposited. 
The Avomb must have returned into the 
pelvis, else she could not have become 
pregnant so often after its exit. 

The diagnosis of procidentia uteri is not difficult. We know it 
from inversion of the uterus and from fibroids 
and other tumors that might be extruded, by 
the form cf the tumor, by 
our ability to recognize the 
lips of the cervix and the os uteri at it? 
lower portion, and by the possibility of pass 
fig. 85. Hornby's pessary. j U g the uterine sound into it. Observe that 
I introduce the sound through the os uteri quite readily and pass- 
its point directly to the fundus. I now withdraw it and show 
you the depth of the womb, which is exactly four inches. 




Fig. 8-t. Fraser's pessary. 




"Diagnosis. 



618 



THE DISEASES OF WOMEN. 



Case. 




Hornby's pessary. 



There is very little doubt that this displacement of the uterus 
followed childbirth, and that the escape of the organ from the 
pelvis was facilitated by its defective involution. 
Ten years ago I gave the class a lecture on 
procidentia, illustrated by a cadaver brought to the table, from the 
dissecting room. All the appearances indicated that the poor 

woman had died directly after la- 
bor. The uterus was not in- 
verted, as it might have been 
from an improper delivery of the 
placenta, but it had been ex- 
pelled ill a perpendicular direc- 
tion with the cervix looking 
downward. I passed the sound 
and showed the class that its 
depth was seven inches, careful 
examination of its textures satis- 
fied us that it was the puerperal uterus which had thus been 
extruded. The case was a very remarkable one. 

Treatment. — There are three methods of treating these cases 
The first is to reduce the dislocation and afterwards to keep the 
parts in apposition, as the surgeons would ^W; 

say, by the adjustment of a pessary which 
would keep the womb where it belongs. 
We shall try this plan first and if it fails, 
must afterwards resort to one of the 
others. 

The second method consists in remov- 
ing a portion of the vaginal mucous mem- 
brane, (Fig. 87) as in 
the operation for cysto- 
cele, and bringing the edges together by 
suture in such a way as to narrow the 

, , . Fig. 87. Incisions and sutures 

vagina and prevent the extrusion of the in Eiytrorrhaphy. 

womb. This is styled eiytrorrhaphy, and in making it, I prefer 

Thomas' operation which I have already described under the head 

Episio-perineor- 01 CyStOCeie. 

rnaphy. The third, consists in freshening the edges 

of the labia and bringing them together by suture so as to close 



Eiytrorrhaphy. 




PROCIDENTIA FROM Pi-.lITl "SSIS. (jld 

the vulvar orifice, excepting only a small opening which is left 
for the discharge of the urine. This operation is termed q)isio- 
2) er in eo rrh ajpliy. 

PROCIDENTIA UTERI FROM PERTUSSIS. 

Case. — At the eighth month of pregnancy, Mrs. , aged 32, 

was seized with a violent attack of whooping cough. The par- 
oxysms ot coughing were so frequent and severe as to threaten 
premature labor; but by careful management she was finally 
brought to term without any serious mishap. After delivery she 
got up well, the violence of the cough gradually abating until, 
at the end of two months, it had almost entirely ceased. With 
the exception of a slight cough, and an habitual constipation 
(which she always has while nursing), she felt herself well. At 
the end of the third month, and while taking her usual afternoon 
drive, she took cold, and the consequence was, a recurrence of the 
whooping cough. The fits returned with their former severity, 
and she "felt as if she should cough herself to pieces." The 
second evening after the return of these trying symptoms, while 
at stool, and during a paroxysm of the cough, she suddenly felt 
something escape the vulva. I was summoned, and arrived shortly. 
The womb had been forced entirely out of the pelvis, and was 
lying between the thighs. It was easily reduced by appropriate 
taxis and the proper treatment was instituted. She made a good 
recovery. 

Pertussis is a rare contingent of pregnancy. This case is, 
therefore, somewhat extraordinary. I have cited it in order to 
Anta°-oni«m of th- ma ke a few clinical points particularly clear to 
diaphragm and peri- your minds. It illustrates the antagonism of 
the diaphragm and the perineum, the former of 
which, you remember, is the muscular floor of the thorax, and 
the latter of the abdomen, or, more properly, of the pelvis. In 
consequence ot gestation, and after delivery, the lateral and in- 
terior supports of the womb are not always sufficient to retain it 
in situ. The ligaments have been stretched and off duty for so 
long a time that they are lacking in tone and strength. The 
vaginal and muscular column resting on the perineum has been so 
relaxed and distended as to yield it but little support from below. 

This state of things predisposes to downward displacements of 
the womb after delivery. If the patient is upon her feet too 
^arly and too frequently, if the womb folds upon itself very 



620 



THE DISEASES OF WOMEN. 



slowly, and its involution is imperfectly accomplished, such mis- 
haps are more likely to follow. Constipation in some lying-in 
women, and diarrhoea in others, are predisponents of prolapsus 
and procidentia uteri. 

Among the exciting causes of these particular displacements in 

lying-in women, and in those who have recently been delivered, a 

violent cough is, perhaps, the most serious. 

Coujrh a cause of u i i • 1 • i ±. 

uterin. displacement. Hence > we may have prolapsus in a slight or 

extreme degree as a concomitant of pneumonia, 

pleurisy, bronchitis, or whooping cough. The pectoral lesion 




Fig. 88. Procidentia of the uterus. 

proper has nothing to do with causing the displacement. The 

cough alone is responsible for it. It acts through the spasmodic 

and forcible contractions of the diaphragm, which it necessarily 

induces. And the more violent the couodrinof fit, the greater the 

danger of this unfortunate result. 

During the fit of whooping cough the convulsive action of the 

diaphragm is sometimes prolonged and painful. In children it is 

very apt to be followed by retching and vomit- 
Labor a predisponent. . , , . . . -T • , i * i 

nig, and sometimes by severe and intractable 
tenesmus of the bowel. In the case of my patient, who had just 
been straining at stool, its effect was to overcome the slight re- 
sistance offered by the sphincter vaginae and the perineal muscles, 
and to empty the pelvis of the womb itself. Of course, this 



PROCIDENTIA FROM PERTUSSIS. 621 

accident would be much more likely to happen at the second or 
third month after confinement than after the vagina and peii- 
neum, as well as the uterine ligaments, had recovered their ton- 
icity, and were better able to sustain the womb, and to retain it 
in its proper place. 

Treatment. — The treatment proper for a case of this kind is 
preventive, postural, and remedial. 

The occurrence of a severe cough during gestation, and espe- 
cially towards its close, should cause you to take especial pains to 
prevent such a sequel to the labor as happened 
in this case. After delivery the patient should 
be kept in the horizontal position for a longer period than usual. 
The binder should be snugly and firmly applied, and she should 
not be allowed to stand upon her feet until three or four weeks 
have elapsed. She should be cautioned against straining at stool, 
or in urinating, and counseled to suppress the desire to cough as 
much as possible. 

Where the womb has really been expelled, the first thing to be 
done is, of course, to replace it. This may be easily accomplished 
in recent cases. Place the patient on her back, 
raise the hips and lower the head. Then, hav- 
ing anointed the hand, grasp the tumor firmly, and insinuate it 
gently within the vulva, passing it first in the direction of the 
vaginal axis, and afterwards in that of the pelvic axis proper. 
When in situ, apply a perineal bandage and pad, which should be 
worn for some weeks, even after the patient has left her bed. 
There is no more natural and effectual support, in a case of proci- 
dentia than this. You can extemporize such a support out of the 
simplest materials. 

The most appropriate and efficient remedies should be given for 
the cough, and every precaution taken to prevent a relapse. This 
is especially important in case of whooping cough, the effects of 
the paroxysm being so disastrous and prejudicial to permanent 
recovery. Cure the cough, and its indirect consequences will 
cease. Stop the convulsive action of the diaphragm, and the 
uterine displacement may not return. 



LECTUKE XXXIX. 

FLEXIONS AND VERSIONS OF THE UTERUS. 

Uteiine Flexions. General remarks upon. Retro-flexion. The touch and the sound in the 
diagnosis of. Case.— Re-position of the organ. Stem pessaries. Ante-flexion. Com- 
parative frequency of. Causes, diagnosis, and treatment. Case.— Latero- flexion. 
Causes. Case.— Symptoms. Contingent affections. Postural treatment. Uterine 
Versions. General remarks upon. Varieties. Retro-version. Clinical history of. 
Ante-v rsion, causes, symptoms, and treatment. Latei'o-version, the rarity of. In- 
version, the clinical history and modern surgical treatment of. 

General Remarks. — In order that you may have a clear idea of 

the nature of uteiine flexions, two facts should be borne in mind : 

(1) that, in this kind of displacement the shape 

Two peculiarities of. " ., . 1 , .. .: . 

of the uterus is always changed, and (2) that 
the flexure occurs at the junction of the neck with the body of the 
organ. Properly speaking, therefore, these deviations are char- 
acterized by a change, or curve in the axis of the womb, which is 
bent like a chemist's retort. 

You know that the uterine cervix is so fixed by its vaginal 

attachment as to be comparatively secure, while the body of the 

uterus has a greater latitude of motion. It is 

The anatomical ^[s arrangement which permits a bending or 

predisponent of. " l rt 

twisting of the organ backwards, forwards, or 
laterally, while its neck is in situ, or very nearly so. These 
flexions are facilitated by the peculiar disposition of the peritoneum, 
which is lacking at, and below the point where the neck and body 
of Ihe womb are joined anteriorly. Indeed, this might be called 
the anatomical predisponent of uterine flexions of whatever 
kind. 

Varieties. — There are three kinds of uterine flexion, (1) retro- 
flexion, (2) ante-flexion, and (3) right or left later o-flexion. 

RETRO-FLEXION OF THE UTERUS. 

We have already considered the relations of retro-flexion to 
obstructive dysmenorrhea, (page 202), but something remains to 
be said upon this subject. This form of flexion is more common 

622 



KETROFLEXION OF THE UTERUS. 



623 



than either of the others, and two causes, in addition to those 
already named, combine to make it so, viz. the 
effect of over-distension of the bladder, and of 
rectal paralysis, with or without obstinate con- 
stipation. This cut gives a good idea of the relations of the retro- 
flexed uterus. (Fig. 89.) 



The bladder and the 
rectum in. 




The touch. 



Fig. 89. lietiY.-tiexion of the uterus. 

The diagnosis of this particular deviation is not difficult. The 

subjective symptoms are not peculiar except that, as in other forms 

of flexion, they are most pronounced at the 

month, and that they usually subside when the 

flow has stopped. 

If the flexion is acute, the ordinary vaginal touch may indicate 
both the direction and degree of the displacement. Madame 
Bovin proposed that in these cases the finger 
should be passed along the side of the cervix, 
instead of before it, or behind it, and the idea is a very good one. 
In the case of virgins, retro-flexion may be recognized by the rec- 
tal touch. 

But since there are so many retro-uterine tumors that resemble 

the form of a retro-flexed uterus, we must appeal to the uterine 

sound as a means of settling the diagnosis. I 

The uterine sound. . ° a . 

have had this patient placed upon the table in 
order to demonstrate the application and utility of the sound 
in similar cases. For this purpose I prefer a Sims' sound to 
Simpsons, the latter being too large and unyielding. 



624 THE DISEASES OF WOMEN. 

Case. — Mrs. , aged 25 years, has been married two years, 

but has had no miscarriage. Before her marriage she had scanty 
menstruation, with bearing down pain in the hips and loins, and 
inveterate headache. The bowels were constipated, and all her 
symptoms were aggravated at the month, as well as by stand- 
ing and walking about. There are no vesical symptoms, but after 
fatigue she has fits of nausea that are accompanied by increased 
headache. 

Observe that the touch finds the cervix in its proper position, or 
nearly so. This is the rule in all cases of uterine flexion which 
are not extreme or complicated. But when I pass the sound the 
direction of its point and of its curve afford a good idea of the 
direction and degree of the displacement. When what we may 
call the pelvic curve of the instrument looks downwards and back- 
wards; when the point of the sound has turned towards the hollow 
of the sacrum ; and when the sides of the handle are reversed, as 




Fig. 90. Ludlam's Repositor. 

you see them externally, we know that the body of the uterus is 
displaced posteriorly. By careful manipulation I have now suc- 
ceeded in lifting it to its proper position, but as soon as I let go of 
the sound the uterus falls back again, and the sound is reversed 
along with it. This you can all see for yourselves. 

There are several modes of repositing the retro-flexed uterus, 
one of which is to raise it to its proper place by means of the sound. 
Another is to use some form of elevator which is especially de- 
signed for the purpose. I prefer my own uterine repositor (Fig. 
90); but Sims' (Fig. 14); or Noeggeraths' eleva- 
o Reposition of the tor (Fig> 91 ^ may answer equally well. Great 

care should be used in their application, advan- 
tage being taken of the prone position, in order to facilitate the 
reposition of the organ. 

The next indication is to keep the uterus in situ. In simple 
cases it will suffice to lift the fundus into place once or twice 






RETRO-FLLXION OF THE UTERUS. 



625 



per week, to replace it a few hours in advance of the monthly flow, 
and to keep the patient lying- on the abdomen 

Keeping it in place. ., . • i i i T i • • + • 

until the period has passed. Ihis is a trying 
expedient, but it may answer the purpose, and enable us to avoid 



the wearing- of instruments. 





'Fig. 91. Noeggerath's uterine elevator. 

The best pessaries for uterine flexion are the straight, split, or 
curved stems, which have 

fie^on^ 68 iQ retr °" beei1 in vo S ue sillce the <%* 
of old Dr. Macintosh. In 

some cases the plain hard-rubber stem will be 

r Fig. 93. Hard rubber 

sufficient (Fig-. 92.) At first it maybe too stem - 

straight to pass the internal os, in which case it may be bent to 
the required curve by holding it over the flame of a lamp. The 
principal objection to this stem is that it is apt to drop out, and 
hence, I prefer Chambers' stem pessary, (Fig. 93), which can be 
readily introduced and which expands in such a way as not to be 
easily displaced. 




Fig. 93. Chamber's stem pessary. 

When the case has almost developed into one of retro-version, 
and the cervix is thrown forwards, if there is no circum-uterine 
inflammation (which is a bar to the use of intra-uterine stems ot 
all kinds), Cutter's stem pessary will answer a good purpose. 
But it should be used very cau- 
tiously. (Fig. 94.) 

The modus operandi of these 
st2ms is by passing 

The retro-uterine through the Canal 
tampon. & 

Ot the Cervix, the fig. 94. Cutter's stem pessary. 

internal os, beyond and the point of flexion, to keep the uterus 

40 




626 



THE DISEASES OF WOMEN 



in its own proper axis. Sometimes we have good results from 
pushing a cotton tampon, which has been anointed with carbol- 
ized cosmoline, into the Douglas' space, where it may be worn for 
some hours or days ; or a little pad of oakum, or of carbolized tow, 
may be placed behind the uterus in a similar manner. 



ANTE-FLEXION OF THE UTERUS. 

In estimating the relative frequency of this form of uterine devi- 




"FiG. 95. Ante-flexion of the uterus. 

ation, we should not forget that before puberty the normal posi- 
tion of the uterus is one in which it is curved 
Comparative fre- verv decidedlv forwards ; neither should we lose 

quency of. : ; d 

sight of the fact that this position of the organ 
may continue during menstrual life, without being in reality 
abnormal. It is only when the womb has toppled over toward the 
symphysis pubis and caused a train of symptoms, more especially 
connected with Urination or menstruation, that the flexion requires 
treatment. 

The causes of anteflexion are chiefly local ; as chronic disease of 
the bladder, with freqnent urination and strangury; stone in the 
bladder ; interstitial tumors in the anterior wall 
of the uterus; tight-lacing, and the ordinary 
causes of uterine displacements. 

The diagnosis is not difficult. The inability to retain the urine 
without suffering, while the patient is upon her 
feet, and the relief afforded by lying upon the 
back, arc invariable symptoms. But you are not to mistake this for 



Causes. 



Diagnosis. 



ANTE-FLEXION OF THE UTERUS. 627 

a daily aggravation, since it is the patient's posture and the con- 
sequent change in the relation of the pelvic viscera that produces 




Fig. 96. Silver uterine probe. 

the symptoms. It she slept in the day and walked about at night, 
the order of things would be reversed, but the clinical significance 
of the symptoms would remain the same. 

The combined touch, the bladder having been first emptied, is 
sometimes sufficient to settle the diagnosis ; but the introduction 
of a silver probe like this (Fig. 96) or of the uter- 
The touch and the - ne soun( j w {\\ |) 6 m0 re thorough and satisfactory. 
Here, as in retro-flexion, the direction of the 
point of the instrument, and the forward and downward inclina- 
tion of its curve, toward the bladder and over it, will also indi- 
cate the kind and degree of the displacement. 

It is not always easy to pass the sound in these cases, and you 
may have to exercise a little tact in introducing it. I have some- 
times succeeded by directing my patient to lie 
How to pass the U p n her back for some hours, in order that the 

sound in extreme A . it 

cases. urine might accumulate, and that the distention 

of the bladder, together with the effects of grav- 
ity, might carry the fundus of the uterus toward the rectum, and 
so straighten its axis that the sound would pass quite readily. 
The urine can then be drawn with a catheter, and the displacement 
identified. 

In very rare cases the canal of the cervix may be so blocked or 
deformed by the presence of a small fibroid opposite the internal 

os uteri and in front of the cervix, that the or- 
a soTnd. reP ° Slt0r aS dinary sound will not pass within the uterus. 

Such a case was sent to our clinic by Dr. Mul- 

holland, of Indiana, last summer (1880). I have already referred 

to this case (page 92), in which you remember I made use of a 

Case Sims' repositor, and passed it readily in place of 

the sound. There is an advantage in using this 
instrument as a sound, for when it has been passed, we are ready 
to lift the organ into place (Fig. 14). 



628 THE DISEASES OF WOMEN. 

The treatment of ante-flexion of the uterus is decidedly influen- 
ced by the disabilities of the patient, and by the kind and degree 
of exercise that she is forced to take. If she can 
lie upon the back and thus relieve the bladder of 
pressure upon its fundus, the uterine walls may recover their tone, 
the organ may lose the habit of careening forwards, and the blad- 
der may become tolerant ot its own proper contents. In the 
milder cases, where the symptoms are worse at the mouthly period 
and almost wholly disappear in the interval, a menstrual quaran- 
tine, with keeping the patient constantly upon her back until the 
flow has ceased will sometimes be sufficient for the cure. This is 
especially true if we are careful also to select such remedies as are 
suited for the regulation of the catamenial discharge and for the 
relief of other incidental symptoms. 

When a mechanical support is necessary, in order that the uterus 

may preserve its own axis, the various stem-pessaries that have 

alreadv been advised in retro-flexion are equallv 

Stem pessaries in. •/ *■ 

useful. They may be worn in most cases with 
impunity, but should not be used if there is endo-metritis, pelvic- 
peritonitis, or pelvic cellulitis. 

LATERO-FLEXION OF THE UTERUS. 

Case, — Mrs. , aged 51, of nervo-bilious temperament, war 

admitted to the hospital one month ago. She has been suffering 
more or less for ten years with uterine difficulties. At forty years 
of age she was treated locally for ulceration of the os uteri, and 
cured. She has had three children, the last of which is sixteen 
years old. She passed the climacteric eight months ago without 
accident, and attributes her present troubles to having to ascend 
and descend thiee flights of stairs at her boarding place last winter. 

She complains of pain in the back and a sense of dragging down 
in the pelvis, profuse vaginal leucorrhoea, and a burning pain in 
the right inguinal region. The last symptom, however, is not 
constant. She cannot lie upon her left side. The right leg is at 
times numb and almost paralyzed. The bowels are tolerably reg- 
ular, the appetite is not very good, the urine is normal. 

Physical examination reveals a right latero-flexion of the womb, 
the body of the organ being apparently adherent to the right wall 
of the pelvic cavity. This deviation of the uterus was corrected 
by means of the sound, which, together with a few doses of nux 
vomica 3d, promptly relieved the paralytic feeling in the right 
limb. The patient was ordered to lie on the left or opposite side 



LATERO-FLEXION OF THE UTERUS. 629 

:and upon the back exclusively. Subsequently she took the citrate 
of iron and strychnine in the third decimal trituration, a dose every 
three hours. 

Cases of latero-flexion are comparatively rare. Nonat met with 

it in but one out of three hundred and thirty-nine examples of 

uterine displacement. As in other flexions of 

^Relative frequency the Qrgan the cervix ig buf . slightly, if at all dis- 
placed, while the body is more or less curved 
upon its neck. The pain and distress are usually referred to one 
side or the other of the pelvis. The womb inclines more frequently 
to the right than to the left side, probably because in a majority 
of cases it has taken that direction during pregnancy. In some of 
these cases it is possible that the involution of 
the womb after delivery may be less complete in 
the right or dependent part of the organ, and that, consequently, 
its increased weight may cause it to topple over in that direction. 
Occasionally it is said to follow as a sequel of chronic metritis, and 
aiso of constipation with paralysis and a stuffed condition of the 
rectum. It may occur in a woman who, being confined to her 
couch, persists in lying day and night, always upon one side of the 
body. Or it may be displaced laterally by direct pressure from 
uterine and ovarian tumors, peri-uterine deposits and pelvic 
abscess. 

The symptoms are not distinctive. Most patients complain of 

burning pains in the iliac or the inguinal regions, which pains are 

severe and protracted, and exte id more or less 

Symptoms. . • . . 

into the corresponding hip and thigh in propor- 
tion as the nerves are pressed upon mechanically, and the free 
distribution of the nervous currents is interfered with. Inability 
to lie on the opposite or sound side is suggestive, although not by 
any means pathognomonic of this particular variety of uterine 
deviation. 

It is only by the introduction of the sound that we can be quite 
positive in our diagnosis. If, after being passed as far as the 

internal os uteri, the point shall enter the organ 

Physical signs. r . n 

and then travel towards the right or left acetab- 
ulum, the concavity of the instrument looking to the correspond- 
ing limb of the patient, it is safe to conclude that she has a lateral 
deviation of the womb. If the direction of the sound is changed 



630 THE DISEASES OF WOMEN. 

when she turns over and lies for a little on the opposite side, the 
displacement is not a very serious affair. 

I have now passed the sound to the fundus uteri. You will ob- 
serve that the roughened surface of the handle, which corresponds 

Passing the sound. to tlie ti P of tne instrument, and its anterior 
curve, looks toward the right thigh of the patient. 
And although, as I have told you, the sound is of little use as a 
means of repositing the organ, still, in these cases of lateral 
displacement, and with proper precautions, it may be of service in 
this way. While she is lying upon the opposite side therefore, so 
that gravity may assist us, we gradually turn the sound, and the 
uterus along with it, until its pelvic curve or concavity looks to- 
wards the symphysis pubis. 

Now the organ is in situ, and the sound has served the double 
purpose of acquainting us with the precise 

Repositing the or- r r , ? & .* 

gan. nature of the displacement, and ot furnishing us 

with a means for its reduction. 

The treatment of such a case as this is very simple. The first 

indication, after having put the organ in place again, is to select 

a proper posture for the patient. Manifestly 

Postural treatment. s } ie snou |(j ]i e on the opposite side, in order to 
keep the womb from gravitating into its unnatural position. 
This woman had right latero-flexion, in which the fundus uteri had 
toppled over against the right side of the pelvis. She must there- 
fore lie upon her left side, if she wants to get well of this diffi- 
culty. There will be no harm in her turning upon the back occa- 
sionally, but she should not permit herself to lie upon the right 
side for months to come. 

This will be a difficult prescription to take. For the first few 
days especially, it will require some moral courage to carry out 

Need of courage. tnese instructions faithfully. She will proba- 
bly have pain in both hips, aching and unrest, 
in consequence. She may lose her appetite, pass sleepless nights, 
and, altogether, feel worse for a time than when she came to the 
hospital. But ultimately her sufferings will be relieved, and she 
will be Had of her <rood resolution. 

These cases are more readily and radically cured than what is 
known as latero-version, a condition in which the uterus is directly 
across the vagina, with the fundus at one acetabulum, and the 
cervix uteri at another. 






VERSIONS OF THE UTERUS. 631 

If the uterus has been flexed laterally for a considerable time, 

it may be so bound down by unnatural adhesions that its reposition 

will be followed by more or less of peritoneal 

Contingent disea- iuflammation< Affain it wi H be followed bv a 
ses. _ o 

species of sciatica, which is persistent and 
troublesome. For the former, such remedies as rhus toxicoden- 
dron, belladonna, or bryonia, may be required. For the latter, I 
know of nothing to compare with colocynth. 

VERSIONS OF THE UTERUS. 

General Remarks. — The chief characteristic of this kind of dis- 
placement consists in the cross-position of the uterus. In con- 
tinned cases of version the womb lies transversely 
JrT„Tl S ° H u fl bet " een in the pelvis, or if its fundus is very much 

versions and flexions. i ' J 

depressed, it lies diagonally across the vagina. 
Versions are more serious and difficult of cure than flexions. As 
a class they are more frequent with those who have borne children, 
while the opposite is true of flexions of tne uterus. Versions are 
less likely to be accompanied by painful, delayed, and difficult men- 
struation than arc flexions ; but the vesical and rectal complications 
are almost always more marked and inveterate in versions, than 
they are in flexions of the womb. In many cases the slighter 
degree of flexions are self limited, and get well spontaneously ; 
but where they persist, the case may develop into a corresponding 
version, and then become chronic. 

My own idea is that most cases of uterine version really begin 
with flexion, and that, either in consequence of neglect, or of im- 
proper treatment, which is worse, thev finally 
of7e r xir s . aSthereSUlt mer £ e illt0 a deviation which involves the neck 
as well as the body and fundus of the womb, and 
finish by throwing the whole organ across the pelvis. 

Varieties. — There are three kinds of version, which take their 
name from the direction assumed by the displaced fundus. Thus we 
have (1) retro-version, (2) ante-version, and (3) latero-version, of 
which there are the right and the left. 

RETRO-VERSION OF THE UTERL'S. 

In retro-version the fundus uteri is thrown backward against 
the rectum, and the cervix forward against or upon the bladder, 



632 THE DISEASES OF WOMEN. 

while the body of the womb lies across the vagina. In extreme 
cases the fundus may full upon the coccyx, or the perineum, while 
the cervix may mount so high that the uterus shall be upside 
down. 

The predisposing causes of retroversion are pregnancy, puer- 

perality, abortion, the abuse of coitus, atony of the rectum, 

constipation, haemorrhoids, chronic dysentery, 

ischuria, obstructive dysmenorrhcea, and certain 

deformities of the pelvis, more especially if it is too capacious, or 




Fig. 97. Retro -version of the uteius. 

if the promontory of the sacrum projects very far forwards. 

The exciting causes are the lifting or carrying of heavy weights, 
a blow or fall upon the abdomen, jumping, running, a sudden jar 
from a mistep, or a violent paroxysm of coughing. 

The symptoms are more abrupt when this deviation occurs during 
early pregnancy than at other times, although as in one of our 
hospital cases it may happen suddenly from 
lifting a bucket of coal, or of water. In most 
cases, however, the symptoms come slowly, and gradually. There 
is pain in the sacral and lumbar region, weight and pressure in the 
region of the cervix, with epigastric uneasiness and distress. The 
rectum is more or less irritated by the pressure of the tumor, and 
there are mucous discharges with more or less tenesmus and in- 
effectual urging to stool. Sometimes there is a complete obstruc- 
tion ot the rectum, in which case the patient's complexion ma}^ 
soon show the dirty gray tint of coprsemia, with a very disagree- 
able odor of the perspiration. 



RETRO-VERSION OF THE UTERUS. 633 

The bladder symptoms are usually less marked than in the 
anterior displacements, but the intimate union between the neck 

of the uterus and the bladder anteriorly, makes 
jhe vesical symptoms it almost impossible to displace the one without 

disturbing the other. According to Rigby this 
form of version may produce engorgement and chronic inflamma- 
tion of the ovaries. When it occurs in early pregnancy there may 
be symptoms of a threatening abortion. If it has come on very 
abruptly, the lower extremities may be partially or wholly par- 
alyzed. 

The reflex nervous symptoms are very troublesome. Next to 
the gastric disturbance, which is almost never lacking, the occipital 

headache, and the pain on the top of the head or 

tom h s ? nerVOUS SymP " about the vertex > is more certain to be present 
than any other subjective symptom. Hysterical 
symptoms of every kind and description may depend upon this 
local cause, and may disappear when it has been removed. The 
effect of retro-version in the production of morning-sickness during 
pregnancy has already been considered. (Lecture XIX.) 

The vaginal touch finds the uterus lower down than natural, for 

confirmed cases of version are almost always complicated with 

more or less of prolapsus. By the finder, the 

Diagnosis. *• 1 ' * i i ipi 

outline oi the body and neck ot the womb can 
be readily felt. 

The rectal touch is often essential to a correct diagnosis, for in 
no other way can the nature of this retro-uterine tumor be so 
thoroughly known. When this form of touch is combined with 
the skilful use of the sound we shall have something to depend 
upon as a means of diagnosis. The conjoined touch, through the 
vagina and the abdominal parietes, may also be used to advantage, 
especially if the walls of the abdomen are not too thick. 

But sounding the uterus in these transverse positions is not 
always an easy matter, and hence its reposition by internal means 

is sometimes very difficult. The directions that 
reduction* m ° 6 ° f are usuaii y given for performing this operation, 

in a bad case of retro-version, are fast becoming 
as antiquated as the old time details of the mode of reducing a 
hip-joint dislocation. For the effects of atmospheric pressure and 
of gravitation are now taken advantage of as an aid, and indeed 



634 THE DISEASES OF WOMEN. 

they are often sufficient to lift the organ into place. The expedient 
of applying atmospheric pressure within the vagina for this pur- 
pose, is another result that rightfully dates from the discovery 
ot the Sims' speculum, by the use ot which, with the patient in 
the knee-chest position, it is best applied. 

The mode of applying pneumatic vaginal pressure, with gravi- 
tation, to the reduction of retro-displacements has been carefully 
and skilfully elaborated by Dr. Henry F. Camp- 
m^d. 0aPPlythiS bell > of Augusta, G-a.* The posture chosen is 
the same that was adopted by Deventer in 1701, 
in the treatment of prolapse of the funis. The patient is placed 
upon her knees with the chest thrown forward upon the bed 
or couch, the hips being raised at an angle of about forty-five 
degrees. This is what is known as the genu-pectoral, or semi-prone 
position. The vagina is then expanded, by the introduction of 
the speculum, the best of which is a Sims', which lifts the peri- 
neum and allows the air to fill the passage. The combined effect 
of gravitation in removing the superincumbent weight ot the 
intestines, and of the steady pressure of the atmosphere, is to raise 
the fundus and to replace the organ. In most cases this will be 
sufficient, but exceptionally you may need to apply direct pressure 
by the finger, or possibly to seize the os with a tenaculum like this, 
and bring it into position. (Fig. 98.) 




Fig. 98. Uterine tenaculum. 

Dr. Campbell recommends a domestic application of this expe- 
dient which consists in the frequent resort to this position, and 
the separation of the labia with the patients 
P a«ent beVSedb ** own nil g ers > or h J the passage of a small tube. 
Patients, he says, can be taught to do this at 
their own homes. 

In the reduction of these dislocations Dr. Guernsey's uterine 
elevator may sometimes be applied through 
the rectum. (Fig. 99.). It is especially adapted 
to retro-version occurring in virgins and during pregnancy. 

In some cases direct pressure maybe applied to the fundus uteri 

*Trans. of the American Gynaecological Society, Vol. 1, p. 198. 






RETRO-VERSION OF THE UTERUS, 



635 



and the organ lifted forward by Armstrongs' fenestrated elevator, 
which is a very simple and useful instrument. (Fig. 100.) 





Fig. 99. Guernsey's uterine elevator. 

In retro-displacements that have been neglected, or mal-treated 




Fig. 109. Armstrong's uterine repositor. 

under the theory that their reposition was very difficult if not im- 
possible, because of peritoneal adhesions, there 
may be so much tenderness and tumefaction as 
to necessitate some treatment before reducing 

the dislocation. The best expedient that I have ever found in 



Preparatory treat 
ment. 




4^ 



Fig. 101. Ftowe's retroversion elevator. 

cases of this kind is the frequent and persistent use of hot- water 
vaginal irrigation. When the swelling is largely in the depressed 
fundus, I have sometimes directed that the water should be 
thrown into the rectum through a double-current sound such as 
you have seen in use in our puerperal wards. In either case the 
patient should be placed in the prone or the semi-prone position. 



631) 



THE DISEASES OF WOMEN. 




Eig. 102. Woodward's retroversion 
pessary. 




Ill a day or two the effects of mal-position, and the strangulation 

of the womb will have passed 
away, after which the organ may 
be reposited as we have already di- 
rected. 

The next thing to be done after 
getting the organ into position is 
to keep it there. If the mere re- 
moval of the weight of the intes- 
tines from above the uterus was all that was necessary, and it 
may be in recent cases, the wearing of 
an abdominal supporter would be suffi- 
cient. But, in chronic and confirmed 
retro-version the external belt supplies 
only one of the conditions that are ne- 
cessary for retaining the or^an in situ. 

n . \„ ■*■. , , Fig. 103. Woodward^ pessary for 

bometnmg more will need to be done retroversion. 

in order that the body and fundus of the uterus may also be lifted 
from their unnatural position. This end is 
secured by the constant dilatation of the 
vagina which provides for the admission of 
air, as in the mode of reposition which 
has just been described. 

Such a dilatation is maintained by the 

Fig. 104. Graily Hewitt's re- various p e S S a r i e S 
troversion pessarv. +i ± i i 

that have been 
used for retro-version, the most popular 
of which owe their reputation to the fact 
that they keep the vagina on the stretch, 
instead of to the crutch-like form that 
has been given them. In one way or 
another they are all modified from the old 
ring pessary which was designed to ex- 
pand the vagina. Hodge's lever pessary 
Fig. 83.) illustrates the idea exaclly, and 
the same principle is applied to both of 
Woodward's pessaries (Figs. 102 and 103) 

Graily Hewitt's (Fig. 104) and Thomas' ^If'J* ™ 5 ' retr °" vcr - 
{Fig. 105) retro-version pessaries unite the double principle of 








RETRO-VERSION OF THE UTERUS. 



637 



leverage and vaginal distension, and are therefore profitable in 
many cases. 

Sometimes we may succeed in keeping the organ in position by 
placing a tampon or other instrument 
in the posterior cul-de-sac. For this 
purpose a Buttle's pessary (Fig. 106) 
may answer, especially if there is a 
coincident prolapsus. Thomas' modi- 
fication of Cutter's pessary for retro- 
version (Fig. 107) puts a crutch behind 
the organ and keeps it forward. In a 
few cases, however, I have found that 
• ^^^^L otters' original pes- 
^^^^^ g sary for retro-version fig.iob. Buttle's pessary. 
^t^^^ 6 (Fig. 26) could be worn when Thomas' modifica- 
^^^^^P tion of it could not. 

Concerning the medical treatment, if the trou- 
ble began in the rectum, and its chief symp- 
tom are dependent upon rectal paralysis, chronis 
constipation, or haemorrhoids, collinsonia can. in the second or 
the third dilution is often an invaluable remedy. It will not cor- 
rect the retro-displacement, but it will do away with many of 




Internal remedies. 




Fig. 107. Thomas' Cutter's pessary. 

the most troublesome rectal symptoms that are connected with 
it. Other remedies that may be especially indicated are nux 



638 THE DISEASES OF WOMEN. 

vomica, podophyllin, alumina, aloes, hamamelis, calcarea car- 
bonica. 

The treatment proper for retro-version during pregnancy has 
already been given in Lecture XIX. 

ANTE-VEESION OF THE UTERUS. 

This drawing (Fig. 108) will give you a good idea of the relative 
position of the uterus when its fundus is thrown forward upon the 
bladder, and its cervix upwards against the rectum, the axis of the 
organ being across the pelvis. 




Fig. 108. Ante-version of the uterus. 1. the rectum. 2. do. lying- upon the uterus. 3, 
The fundus uteri. 4. the bladder 5. the urethra. 6. the vagina. 

Observe that the bladder is almost inverted, that the rectum is 
partially obliterated, and that the vagina is put upon the stretch. 
When the uterus is also prolapsed, its fundus may press the ure- 
thra firmly against the pubis. The greater the degree of this 
transverse displacement, the greater the acquired deformity of 
each and all of these pelvic viscera. Consequently the functional 
derangement of the bladder, and of the rectum especially, will 
vary in a corresponding ratio. They will also become chronic if 
the duration is permanent. 

Ante-version is less frequently met with than ante-flexion. The 

chief complaint is of symptoms that resemble those of cystitis, for 

which, indeed, it is often mistaken. Naturally 

enough the vesical symptoms are worse when 

the patient is standing or walking, and sometimes there is such an 

absolute inability to walk, or to stand, that those who hav e 



ANTE-VERSION OF THE UTERUS. 639 

ante-version become bed-ridden. Owing to the partial oblitera- 
tion of the bladder, its capacity is so diminished that only a small 
quantity of urine can be retained within it, and this causes a very 
frequent and painful urination. 

The rectal symptoms are not always present. In bad cases the 
cervix may retreat so far into the hollow ot the sacrum as to 
obstruct the passage ot faecal matter and occasion tenesmus, and 
diarrhceic or dysenteric symptoms. If there is any difference be- 
tween ante- version and retro-version in so far as these peculiar 
symptoms are concerned, it is that, while in the former, lying on 
the back mitigates the tenesmus, or the constipation, it is not so 
in retro-version. 

Courty says: "With several patients who had retro-version it 
has seemed tome that, whether applied with the hand, temporarily, 
or constantly with the abdominal belt, pressure 
upon the hypogastrium tended to increase instead 
of to lessen the suffering; while the contrary was the rule in ante- 
version." * 

Beside the subjective symptoms, the physical signs are also 

important and essential to a correct diagnosis. The touch applied 

along the sides of the uterus, the remoteness of 

Physical signs of. . , . , . . . . 

the cervix, its being carried in the direction of 
what the old doctor called the "premonitory" of the sacrum, will 
help us to decide the question. If to this we add the conjoined 
palpation, through the vagina and around ^i^^B^fc|^. 
the symphysis pubis, the case may almost al- i4^^^^^-'-'-' : "^^^pk 
ways be clearly made out. Even the rec- BF ^^llk fll 

tal touch has a negative value when the Ilk llL Jm 

fundus uteri cannot be found posteriorly. ^^(l&SlgB fpP^ 
When the sound or the probe can be passed, 

the direction of its point and curve will be V e*s?onTessary ChCOek ' S ante " 
almost if not quite as distinctive as in ante-flexion; and the 
-effect of the dorsal decubitus with the hips raised will assist in 
the differentiation. 

The reposition of the organ is facilitated by keeping the patient 

on her back and thus permitting the bladder to 
displacement. * the become filled, after which the hips may be raised 

so high as to bring gravity to our aid. At the 
same time the air may be admitted into the vagina by lifting its 

*Traite Pratique des Maladies de l'Uterus. des Ovaries et des Trompeo, par A. Courty. 
Prolessor, etc., deuxienne Edition, Paris 1872. page 863. 




m. 



640 THE DISEASES OF WOMEN, 

anterior wall with a Sims' speculum, or with the depressor. 
With this exception the directions that I have given you for the 
correction of retro-displacements apply also to this form of version. 
There is a form of Cutter's fenestrated pessary which is suited 
to ante-version. Beside that, there are modifications of the ring, 
and of Hodge's pessary, which are suited to these 

Means of support. o l J ' 

cases, more especially because they serve the pur- 
pose of separating the vaginal walls so as to secure the admission 

of air. Among them are Hitchcock's (Fig. 
109), and Kinlock's (Fig. 110), ante-ver- 
sion pessaries. 

Abdominal supporters are more useful 
n ante-version than in retro-version. The 

Fig. 110. Kinlock's ante-ver- , , .. , 

sion pessary. dorsal position, at least for a portion of the 

time, is almost indispensable for the cure of these cases, some of 

which are very much benefitted by cultivating 

Best and remedies the haMt oj . Naming the urine for a few hours 

at a time. The incidental symptoms may re- 
quire to be relieved by internal remedies such as cantharis, bell- 
adonna, mercurius, hyoscyamus, digitalis, nux vomica, and tere- 
binth. 

LATERO- VERSION OF THE UTERUS. 

This form of uterine version which is exceedingly rare is almost 

always due to a fall upon one hip or the other, to lesions that have 

been acquired during the lying-in, or to the pres- 

Peculiarities of. ' . °. 

ence of tumors or of dropsical and other accu- 
mulations which force the womb out of place. This version is 
also characterized by a transverse position of the uterus, but, 
instead of lying across the pelvis in an anteroposterior direction, 
the fundus is at one acetabulum and the cervix at the other. 

The subjective symptoms are not characteristic. The chief com- 
plaint is of neuralgic pains which are persistent, which radiate 

through the pelvis and the abdomen, and which 

toms bJeCtiVe SymP " are likej y t0 affect the sacral nerves in their 
distribution to the lower extremities. The ves- 
ical and rectal symptoms are incidental and not constant. 

The physical diagnosis is practised in the same manner as for 



LATERO-VERSION OF THE UTERUS. 



641 



Treatment. 



other forms of version. The touch, conjoined manipulation, pal- 
pation by the rectum, and the use of the sound 

Physical signs. 

are the means at our command. 
The treatment does not differ essentially from that of the other 
varieties of version. The uterus is to be restored to its proper 
position by a similar means. There are no in- 
struments which are of practical use in this form 
of latero-displacement, and we are obliged to depend upon the 
postural treatment rather than upon pessaries or supports of any 
kind. 

An essential part of the treatment consists in recognizing and 
removing the cause of the difficulty. If it is traumatic the inter- 
nal use of arnica, hypericum, or rhus tox. may be required. If it 
is post-puerperal there may be lesions of the pelvic, serous or cell- 
ular tissue that will need to be treated. If it depends upon the 
presence of tumors in the broad ligament, the ovary, the bladder, 
the rectum, or even the bony pelvis, these tumors will require 
special treatment before the version itself can be cured. 



INyERSION OF THE UTERUS. 



In this form of displacement the uterus is partially or wholly 
turned inside out. In the slighter degree the fundus is dimpled, 




Fig. 111. Inversion of the uterus. 

indented, or depressed toward the cervix. The inversion may be 
complete even before the tumor is expelled from the vagina. This 
condition is shown in the diagram. (Fio-. HI.) 



642 THE DISEASES OF WOMEN. 

In the chronic iorm, apart from the puerperal state, the inverted 
organ is more apt to be extruded from the vulva. 

The predisposing causes of inversion are childbirth, and the 
development and distension of the uterus by contained tumors and 
fluids. The exciting causes are traction on the 
placenta or the umbilical cord; rapid labors; 
rigidity of the uterine cervix with a laxity of the muscular fibres 
of the body and fundus; the artificial extraction of the child in 
case of uterine inertia, and the dragging effect of fibrous growths 
and polypi when they are attached to the fundal zone of the 
uterus. When inversion follows labor it may happen immediately, 
even before the placenta has been detached, or it may occur as late 
as the tenth day. Although the gynaecologist does not always see 
these cases in the acute stage, yet 75 per cent of them date from 
delivery; and 20 per cent are due to the traction of intra-uterine 
fibroids and sessile polypi. 

The symptoms vary with the stage and the more or less recent 
occurrence of the accident. If it has happened very recently they 
will be more alarming and dangerous on account 
of the haemorrhage, the shock, and the accom- 
panying depression and collapse. In chronic cases,, the patient 
complains of uneasiness and distress, with a feeling of pelvic 
strangulation that arises from the presence of the tumor. The 
same cause may L produce a tenesmus of the rectum and of the blad- 
der, with sacral and lumbar pains, all of which are very much 
increased by standing or walking. 

Another symptom is the occurrence of a haemorrhage from the 
surface of the tumor, which is periodical, and menstrual in char- 
acter. This haemorrhage is prevented from being very copious, at 
least in chronic cases, by the contraction of the cervix, which acts 
as a tourniquet upon the tumor. 

The tumor is a globular mass, that is more or less soft and 
flabby to the touch, abraided from exposure, which causes a muco- 
purulent leucorrhoea, and is largest at its lower 
extremity. Its size varies with the complete- 
ness of the inversion, and with the nearness to the lying-in period. 
For the inverted uterus may be carried outside of the body for 
twenty years or more. The tolerance of this unnatural condition 
is greatest after the menopause. In very rare cases there is a 
spontaneous reduction of the displacement. 



INVERSION OF THE UTERUS. 643 

In a recent case, where the placenta is still adherent, the diag- 
nosis will be plain enough. But when months or years have elapsed 
since the inversion took place, great care will be 
required. You would know such a case from one 
of procidentia, by failure to lind the os-uteri, and one or both lips 
of the cervix at the lower end of the tumor ; 
and by the inability to pass the sound, as you 
have seen me do it, in procidentia. 

The diagnosis of partial inversion from a case of sub-mucous 
fibroid, is sometimes very difficult. Tlie sound in utero gives 
precisely the same indications, and the diagnosis 
aST a sub " mucous must therefore be made by the conjoined manipu- 
lation. By this means we may recognize the 
rotundity of the uterus in the case of a fibroid, and the dimpled, or 
invaginated fundus if there is a partial inversion of the uterus. 
You may remember also that while the uterine surface of a tumor 
is sensitive, you may pinch, or push a needle into a polypus or a 
iibroid without causing pain. 

The most absolute test for inversion is the same that is applied 

in the case of absence of the uterus, id est the passage of the sound 

into the bladder, with its point looking back- 

Thf* cruoifil tpst "for 

wards, and of the finger, or a large bougie into 
the rectum. If these two meet readily, the inference is that the 
womb is absent, the same as if it were congenitally lacking. 

The greatest care should be exercised in the diagnosis for it has 
happened that the inverted womb has been amputated, under the 
supposition that it was a polypus or a fibroid. 

The prognosis varies with the acuteness of the case, the possi- 
bility of the immediate reduction of the tumor, the degree of the 
haemorrhage and the anaemia, the severity of the 
shock, the lax and diseased condition of the 
uterine parietes, the sloughing and the risks that attend upon all 
forcible attempts at re-inversion. When the displacement has 
become chronic and developed a cachexia with a low vitality of 
the tissues and an impoverished state of the blood, it will not be 
safe to promise a cure, even although we may succeed in reposit- 
ing the womb. 

The treatment for this form of clisp lacement is beset with pecu- 
liar difficulties. The first indication is to reduce, or to re-invert 



644 THE DISEASES OF WOMEN. 

the organ by forcing- its body and fundus through the constricted 
cervix. If the tumor is lar^e from ag-e or expo- 

Treatment. ox 

sure, and the utero-cervical orifice is narrow, as. 
it almost always is, this operation m;\y be impracticable. For it 
is this orifice, which Mauriceau compared to the neck of a phial, 
that interferes with the ready replacement of the womb, and the 
constriction of which it is sometimes quite impossible to overcome. 
In recent cases of inversion occurring in obstetric practice, the 
parts are in such a condition that prompt and immediate action 
m acute cases. will generally be successful. If the placenta 

remains attached, strip it off carefully, and then 
apply steady pressure with the tumor in one hand, while the other 
hand is placed for counter-pressure above the symphysis pubis. 
Be careful, however, to begin the inversion about the neck of the 
organ before you indent the fundus. You will find some very 
interesting and instructive cases of this kind reported by Dr. L. 
M. Pratt/ol Albany, *; Dr. A. K, Thomas, of Philadelphia, t; 
Dr. Mary Safford Blake, J; and Dr. C. G. Higbee, of St. Paul, 
Miun., I. 

When inversion follows abortion, which is very rare, and of 
very doubtful diagnosis, the reduction is usually spontaneous. . 

But in confirmed cases of inversion that have 

After abortion. . .. „ . . 

existed for months or years, nature is not dis- 
posed to aid the re-inversion. 

Taxis and vaginal pressure are the principal means for reducing 

the dislocation, and since a too forcible manipulation by the hand 

may result in a laceration of the soft parts, espec- 

Manual treatment . " . . 

ially it it is continued for a long time, elastic 
pressure by a rubber pessary may be alternated with it. But 
before the attempt is made to replace the organ the bowel and 
the bladder should first be emptied. If the uterus is still within 
the vagina, it may be well to apply hot- water injections as a pre- 
paratory means. Anaesthesia is necessary for the relief of pain and 
for the relaxation of the soft parts, more especially of the cervical 
ring. 

A gradual replacement is safer than a rapid one, and the manual 

*. Trans, of the New York. Horn, Med. Society, New Series. Vol. 1, p 353. 

+. Trans, of the American Institute of Homoeopathy, Twenty-fifth session, 1862, p. 36& 

*. Do, do. do. do. for 1873, page 503. 

§. The United States Med. and Surg-. Journal. Vol. IV. p. 216. 



INVERSION OF THE UTERUS. 645 

method, with proper precautions, is better than the instrumental 
one. In the attempt at reduction by the hand, two indications 
must be kept in mind; (1) to dilate the contracted ring of the 
cervix by counter-pressure through the abdominal parietes, and 
(2) by steady and continuous pressure to force the inverted fundus 
through it. 

In Dr. Tait's method the first of these indications is met by 

the introduction ol the index finger of the left hand into the 

bladder, aud the index of the other hand 

re^almerhod! 68100 ' int ° the rectum « Then the fill g ers approach 

each other and are in position to stretch the cer- 
vical ring, while both thumbs are made to press the fundus 
upwards and towards the cervix. The possible success of this 
method is shown by the fact that Dr. T. reduced a case of inversion 
of forty years standing, in the space of half an hour. Once begun 
the reduction was finished by pushing up the fundus with a tallow 
candle that was Avrapped in a rag. The external os was closed by 
a silver suture, which was removed on the third day, and the 
patient recovered without a bad symptom* 

Courty's method consists in first drawing the uterus outside of 
the vulva, if it is not already there, in passing the index and medius 
of the rio-ht hand into the rectum, and above 
method 7 S rectal the uterus, and then by curving the fingers for- 

ward using them to dilate the cervical orifice. 
The body of the organ is then seized by the left hand, pushed 
into the vagina and moved in different directions so as to facilitate 
its re-inversion, the thumb and the index being pressed upon the 
pedicle of the tumor. It would be well to try this plan before 
dilating the urethra and operating through the bladder, as prac- 
tised by Dr. Tait. Dr. Watt's method is really the same as Cour- 
ty's 

Another means of manual reduction is known as Noeggerath's, 
which consists in the usual counter-pressure over the pubis, and 
in direct pressure upon the cornua of the uterus 
thod. ° with the finger and thumb until the indentation 

has begun, first in one corner, and then in the 
other, after which the center of the fundus is depressed, and the re- 
Inversion is completed. If the patient is a thin person the coun- 

*The Cincinnati Lancet and Observer lor Marcn 1878. 



646 



THE DISEASES OF WOMEN 



ter-pressure, according to Dr. Thomas, may be made to reach the 
cervical ring through the abdominal parietes. 

But you are not to suppose that the trouble is over when a por- 
tion or even the whole of the body of the uterus has passed 
through the internal os ; for it may be quite as difficult to finish 
the replacement as it has been to carry it thus far. Unless the 
operation has been a very rapid one, the anaesthetic will need to 
be withdrawn, and for the present, at least, it may be necessary 
to relinquish any further attempt at 1 eduction. In this case Dr. 

Emmet advises to stitch the os uteri with a 
ent EmmetS expedi " silver suture as a temporary expedient. If it 

is possible, however, the re-inversion should be 
completed at once by pushing up the fundus with a stick of hard 




Fig. 112. Mode of re-inversion in Dr. Ellis' case. 

rubber or ol wood, or even with a tallow candle if you can find one. 

Drs. Sims and Barnes have advised that, where 

Sim's and Barnes' tn e cervical orifice will not yield and the reduc- 

method. . . ... 

tion isotheiwise impracticable, an incision may 
be made upon each side of the cervix. This expedient is seldom 
necessary. 

Vaginal elastic pressure in aid of the re-inversion may be steadily 
and constantly applied by means of air pessaries, and, water bags, 
or by cups that are mounted upon a stem. These may be kept in 
place by a T bandage. A very interesting case of inversion wa& 



INVERSION OF THU UTERUS. 



647 



reported to one of our journals some years ago, by Dr. E. R. Ellis, 
of Detroit. The case was of eight months duration, and in 
reducing it utero-vaginal pressure was continued at intervals for 
the space of nineteen days, by this instrument. (Fig. 112.) 

The mode of applying vaginal pressure that ismost popular just 
now is known as that of Dr. J. P. White, of Buffalo. It is sim- 
ple, rapid, efficacious, and quite safe, if properly 

Dr. White's method. -, ' , ,, ., -. 1 ' , 

used. A glance at the repositor, and at the 
accompanying cut, will explain its modus operandi. (Fig 113) 




Precautions. 



Fig. 113» White's repositor for inversion. 

In all cases in which an attempt is made at immediate instrumen- 
tal reduction the eifort, if unsuccessful at first, should not be con- 
tinued for more than one or two hours, other- 
wise fatal peritonitis or cellulitis may result. 
Nor should it be repeated in less than thirty-six to forty-eight 
hours afterwards. Several fatal cases are recorded in which this 
rule was not followed. 

Where judicious taxis and elastic pressure have failed and it 

becomes a question whether the uterus should be 

amputated, Prof. Thomas' method of opening 

the cervical ring so as to reposit the organs 

should be carefully considered. This method, which is one of the 



Dr. Thomas' meth 
od. 



648 THE DISEASES OF WOMEN. 

boldest achievements of American surgery, consists "in abdominal 
section over the cervical ring, dilatation with a steel instrument, 
made like a glove-stretcher, and reposition of the inverted uterus 
by any one of the methods mentioned, by the hand in the vagina." 
Amputation has been practised as a dernier ressort, but it is a very 
dangerous one, from risk of haemorrhage. Perhaps the safest method 
is that of Courty, who surrounds the neck of 

Amputation. 1 

the organ with a rubber ligature, that may be 
tightened on the second day, and which secures a complete repara- 
tion of the womb in a fortnight or less. When the knife or the 
ecraseur are used, the tumor should first be Heated for two or 
three days. The galvano-cautery is objectionable on account of 
the danger from secondary haemorrhage. 

SURGICAL OPERATIONS FOR RETRO-DISPLACEMENTS. 

Alexander's operation consists in making an incision of from 
one and a half to three inches along the inguinal 
Alexander's operation, canal, down upon the external abdominal ring, 
freeing the round ligaments and drawing them 
out through the wound. The fundus uteri is then lifted forward 
into position, a "run" is taken in the ligaments after which they 
are cut off and stitched into the wound by the sutures that close 
the incision. Drainage, keeping the uterus in situ by a galvanic 
stem, and rest, are requisites to success. The author insists that 
the difficulty of finding these ligaments can only be avoided by 
experiments on the cadaver. 

Hysterorrhaphy, which was first practised by Kceberle in 1869,* 
is being perfected in its technique and promises 
Hysterorrhaphy. excellent results in unconquerable cases of re- 
troflexion and of prolapsus. Its steps include 
laparotomy, the reposition of the uterus, the removal of one or 
both ovaries (if necessary), and in so stitching the womb as that 
its fundus shall lie against and become adherent to the abdominal 
parietes. 

* Archives de Tocologie, etc., Paris, 1877, page 548. 



LECTURE XL. 



ULCERATION OF THE WOMB. 

General observations on uterine ulceration. Varieties of. Simple ulcer of the uterine 
cervix. Aphthous ulceration of the os and cervix uteri. Irritable ulcer of the uter- 
ine cervix. Diphtheritic ulceration of the os uteri. Post-partum ulceration of the 
womb. 

General observations. — The subject of uterine ulceration has 

acquired a new interest of late. A few years ago ulceration, with 

or without induration of the cervix, was gen- 

influence of modern « thought to be the essential and funda- 

views on ulceration. J » 

mental lesion in most of the diseases of 
women. For thirty years, indeed, this idea domiuated, and the 
practice was to rely upon local treatment, exclusively. But, now 
that w r e can differentiate more closely, we know that ulceration 
of the cervix uteri is really infrequent, and that the appliances of 
the Bennet school of gynaecologists were often brought to bear 
upon a lesion which had no existence until it was induced by 
the treatment. 

It is pleasant to think that such a result has been brought 
about by clinical, painstaking, study and experience; and that 
henceforth the poor women are to be spared the suffering and the 
harm that have been unwittingly and unnecessarily inflicted upon 
the sex for a whole generation. 

Uterine ulceration may be a local or a constitutional disease. 

The forms of this ulceration that are purely local are abrasion 

with simple and irritable ulceration. The 

V«iriG"ti.6S 

constitutional varieties include the aphthous, 
the scrofulous, the varicose, the diphtheritic, the syphilitic, and 
the cancerous form. The special pathology of each and all of 
them is very important not only in a diagnostic, but also in a 
curative point of view. We shall consider some of them separ- 
ately, reserving to a future occasion what we have to say of can- 
cerous ulceration. 



650 THE DISEASES OF WOMEN. 



SIMPLE ULCER OF THE UTERINE CERVIX. 

Case. — Mrs. T •, aged 28, mother of one child, has been ill 

for six months. She complains of weakness and debility, which 
incapacitate her for her daily duties. There is a great deal of 
pain in the sacral region, dragging in the loins, and bearing-down 
sensations when she is upon her feet for any considerable time. 
Internally she feels a sense of swelling and fullness within the 
vagina, and of burning at its upper portion. At times there is 
quite a free leucorrhceal flow, which is of a bland unirritating 
character. Examination with the speculum reveals a simple ulcer 
of the size of my thumb nail, situated chiefly on the posterior lip 
of the os uteri, and extending within the orifice. 

The subjective symptoms of this, as of most other varieties of 

uterine ulceration, are not peculiar. The patient may complain 

of pain in the sacrum, the hips, the thighs, 

Subjective symptoms. " . . 

the coccyx, the symphysis pubis, the hypogas- 
tric, or the ovarian regions. There is a sense of weight and 
fullness, of weakness and bearing-down in the region of the 
womb. She has, perhaps, great lassitude, with an almost 
insuperable dislike of mental and physical exertion. Leucor- 
rhcea and painful menstruation are frequent and trouble- 
some concomitants. In some cases, as in this one, there is a 
sense of tumefaction, and of local heat in the parts affected. 
This symptom is especially tormenting after the menstrual dis- 
charge has ceased, and also after coitus. Not nnfrequently there 
is an aversion to sexual congress, and when complicated with 
vaginitis, the act is likely to be followed by a bloody discharge. 
The reflex hysterical symptoms are numerous and varied. Such 
patients are prone to be hypochondriacal, and sometimes exhibit 
strong tendencies towards insanity. 

The objective local symptoms revealed by the "touch" and the 
uterine speculum are peculiar, and we must rely upon them as 

diagnostic. The ulcer, the shape of which 

Objective local symptoms. . . 

is irregularly circular, may occupy one or 
both lips of the cervix, although the posterior lip is its most 
frequent seat. For this latter reason the slightly curved 
speculum is sometimes preferable in making an examination. 
The lesion sometimes extends within the os and along the 
cervical canal. On removing: the accumulated secretion from the 



SIMPLE ULCER OF THE UTE*RINE CERVIX. Qjl 

orifice with a pair of long dressing-forceps and a bit of charpie or 
cotton, and expanding the bi-valve speculum, if you use it, the 
ulcer is freely exposed. There is necessity for care in all these 
manipulations of the cervix, on account of the extreme delicacy 
of the structure implicated. This ulcer within the os and the 
canal of the cervix is sometimes the last and most difficult part 
to heal. Indeed it often happens that such cases are dismissed as 
'cured, when only the mucous membrane exterior to the orifice 
has been healed. 

The simple ulcer is superficial, not excavated, and its margins 

may be irregular, wavy or stellated. In some cases its borders 

are slightly raised and cord-like to the " touch." 

Appearance of. . . 

The color is usually scarlet, evincing a re- 
markable degree of vascularity. Sometimes however, it is of a 
dark or dusky-red hue, resembling erysipelas. This blush may ex- 
tend beyond the border of the ulcer itself. The more protracted 
the case, the darker and more livid the complexion of the ulcer. 
The surface is almost always covered with a muco-purulent secre- 
tion, which must be wiped off carefully. 

In an acute case the part looks as if a corresponding extent of 
its investing epithelium had been stripped off. Sometimes there 
is a simple erosion, which Kennedy has compared to excoriations 
of the glans penis, and to aphthous ulcers in stomatitis. The 
cervix is swollen, congested and sensitive. When the lesion has 
existed for a considerable time, it has a suppurating surface, and 
it becomes the source of an intractable and exhausting leucor- 
rhcea. At this stage the simple ulcer may degenerate into the 
fungous, or granular variety, of which we shall have more to say 
hereafter. 

The most common causes are painful, forcible and too frequent 

intercourse ; coitus during or directly after menstruation, while 

the uter o-vaginal mucous membrane is very vas- 

Causes. , . . . 

cular and sensitive to mechanical injury ; dis- 
proportion in length between the male organ and the vagina ; 
the injudicious use of astringent and harmful injections per 
vaginam ; cold ; insufficient clothing of the inferior extremities ; 
vaginitis ; and friction of the parts from walking when the uterus 
is prolapsed upon the perineum, are among the more frequent 
causes of simple ulceration of the os and cervix uteri. Tyler 



652 THE DISEASES OF WOMEN. 

Smith is of opinion that the corrosive properties of the leucorrhoeal 
discharge may occasion this form of ulceration, when brought into 
contact with the surface. 

This form of uterine ulceration is especially apt to occur soon 
after marriage ; or it may be caused by too prolorgecl nursing. 
According to eminent authorities, among whom are Churchill, 
Bennett and Whitehead, it may result in abortion and sterility. 

The treatment proper for this variety of ulceration is consti- 
stitutional and local. The internal remedies most frequently indi- 
cated are, arsenicum alb., arsenicum jod., nitric 

Treat7nent. 

acid, belladonna, arnica, ignatia, aurum mur., 
mix vomica, sepia, and sulphur. Incidental complications, of 
course, require intercurrent and appropriate remedies. 

The local treatment should be as soothing as possible. The 

principal indication in most cases is to prevent the contact of the 

vaginal mucus and of the leucorrhoeal discharge, 

Topical treatment. 

and so to protect the denuded surface from the 
influence of atmospheric air as to facilitate the reproduction of the 
proper epithelial tissue. If the ulceration is of traumatic origin, 
you may prescribe vaginal injections of dilute arnica with glycerine- 
If the leucorrhoea is purulent, or muco-purulent, it may be better 
to substitute calendula for the arnica. Other topical expedients 
are injections of an infusion of flax-seed, or of dilute glycerine, 
which does not become rancid ; the direct application to the ulcer 
of a watery solution of gum tragacanth, or of a solution of loaf- 
sugar ; painting the ulcer with collodion, or with glyceroles of 
iodine, hydrastin or aloes. Latour's oleaginous collodion is prefer- 
able to the ordinary collodion, because it does not cause pain 
by its shrinking. 

This last preparation has other merits which commend it as an 
external application in abrasion and in superficial ulceration of 
the cervix. It is flexible and water-proof, like a thin layer, or 
pellicle of india-rubber, and hence it protects the surface that it 
covers from contact with the uterine and vaginal secretions. Be- 
fore applying it with the cotton brush the surface of the ulcer 
should be dried very carefully. The coating that forms will re- 
main for from two to five days. Here is the formula for its prep- 
aration : 






APHTHOUS ULCERATION OF THE CERVIX UTERI. 653 

-R Ether sulph., grammes 400. 

' Alcohol, " 100. 

Gun-cotton, 35. 

Ol. Uicini, 35. 

Mix the three first ingredients thoroughly, and when dissolved, add the castor oil. 

APHTHOUS ULCERATION OF THE OS AND CERVIX UTERI. 

Before showing you an interesting case of apthous ulceration of 
the uterine cervix, I must remind you that this is really and most 
decidedly, a constitutional affection; and that it is not marked by 
any subjective symptoms which are peculiar or valuable, in so far 
as the differential diagnosis and the treatment are concerned. 
Without a local inspection of the lesion, its recognition would be 
as impossible as it would be to identify the eruption of scarlatina 
without seeing it ; nor could we know what we have cured, if we 
are successful, without a careful visual examination ot the cervix 
to begin with. For this is a local affection of constitutional ori- 
gin. 

Case. — Mrs. S , forty years of age, the mother of four 

children, has been ill for eighteen months past. She is pale, and 
has the worn look of one whose strength has been exhausted either 
by a drain of the vital fluids, or from inanition. She has a slight 
leucorrhcea, but the discharge bears no relation to the month, and 
from her description appears to be exclusively vaginal. There is 
at times much burning in the vagina, and at the neck of the 
womb. This is aggravated by standing a long time, or by riding. 
It is also apt to be worse in the evening. Sometimes there is 
strangury, but it is of brief duration and not very severe. There 
is not a great deal of inter-pelvic pain and distress. Her appetite 
is poor and capricious. Her food k * does not appear to do her any 
good." Her nervous system is shattered. She cannot sleep, is 
exceedingly anxious about her children, and, in short, hl nothing 
goes right any more." On examination the vagina is found to be 
considerably inflamed, hot and dry, and the anterior lip of the 
uterine cervix to be the seat of an aphthous ulcer, which is twice 
the size of the thumb nail. The only treatment she has had was 
a four months' course of bi-weekly cauterizations, from which her 
health became so bad that she was obliged to stop taking them. 

This form of uterine ulceration begins with a slight vesicular. 

or herpetic eruption, which is located upon the cervix. The 

vesicles, which are as delicate as those of vari- 

The eruptive stage. . _ 1 , 

cella, soon burst, the epithelium becomes de- 
tached, and small curd-like spots appear. With a pencil-brush 
these spots can be easily removed, and the denuded surface re- 
mains a bona fide ulcer. If a number of these vesicles coalesce, 



654 THE DISEASES OF WOMEN. 

they finally develop into an extensive patch of ulceration. Some- 
times the ulcers are small, yellow and of regular outline ; again 
they are much larger, with an inflamed base and an irregular 
ragged outline. Now and then the serum discharged from the 
vesicles is so acrid and excoriating as to inoculate the neighboring 
surfaces. 

The chief characteristics of the aphthous ulcer, however, are its 
shallowness, its being preceded and accompanied usually by the 
herpetic eruption on the cervix uteri, and the 
repeated attempts and failures to reproduce the 
proper investing epithelium. The surface of this ulcer, as seen 
through the speculum, is half concealed beneath an abnormal in- 
vestiture, which is constantly being exfoliated and reproduced. 
In this respect it resembles the aphthous ulcer of stomatitis, and 
like it, is an evidence of a depraved state of nutrition, a kind of 
scorbutic cachexia. 

The diagnosis is very important, for it has very much to do 
with the treatment and conduct of the case. The only forms of 
uterine ulceration with which this is liable to be 
confounded are the diphtheritic and the syphi- 
litic. From the diphtheritic ulcer it may be known by the deli- 
cate and imperfectly organized structure of the membrane that 
covers the ulcer, which in respect of its color and thickness, is 
very different from the wash-leather deposit in diphtheria. The 
attendant constitutional symptoms are much more grave in diph- 
theria than in an ordinary case of aphthous ulceration. 

The syphilitic ulcer is of a dark, red hue, and never bright or 
yellow, and the general constitutional symptoms are wholly dif- 
ferent from those which are incident to the aphthous form of 
uterine ulceration. 

The principal causes of this disease are defective nutrition, an 
impoverished state of the blood, chlorosis, 
tabes mesenterica, chronic gastritis or gastro- 
enteritis, and the exhausting processes of gestation and lactation. 
The treatment is very simple, and if properly chosen, very suc- 
cessful. Much depends upon the correct diagnosis of the difficulty. 
Such cases are sometimes cured unwittingly, 
and neither the doctor nor the patient knows 
what has been done. More frequently, however, they are made 






APHTHOUS ULCERATION OF CERVIX UTERI. 655 

worse by the treatment adopted. This result may often be as- 
cribed to the fact that physicians do not always discriminate as to 
the particular variety of ulceration with which they have to deal, 
and that the means chosen are inappropriate, too harsh, and there- 
fore harmful. It is not at all unusual for the simplest cases of this 
kind to run along for months, and finally, for them to be nearly 
or quite sacrificed upon the altar of a promiscuous cauterization. 

Let me tell you, gentlemen, that in the whole range of our art, 
I do not know of any temptation to compare with that which 
sometimes prompts and permits the physician to diagnosticate and 
to pretend to cure the most serious uterine diseases when they 
have no real existence. Patients not unfrequently declare them- 
selves ill with some particular " weakness," and, whether they 
are mistaken or not, will insist upon being treated therefor, either 
-at our hands or by another. The fashion is to gratify them, and 
to put a premium upon every kind of local expedient especially. 

Thousands of women have thus been cauterized for uterine 

ulceration which, before the application of the escharotic, had no 

existence. Multitudes of them have done 

Reprehensible practice. , . 

penance by wearing pessaries, and supporters 
of every description for luxations of the womb that could not be 
found, except in their own imagination, or in that of the physician. 
They have been bed-ridden and abused until the weakness of the 
sex has become a by-word and a reproach, mainly because the 
doctors have been too anxious to " make out a case ;" and after- 
wards, because they have seen fit to persecute them with the most 
harmful appliances. 

The doctor who treats a broken leg or a case of small-pox must 
be skilled in diagnosis, and measurably honest. His selfishness 
may prompt him to make his patients as many visits as possible, 
and to extort a fabulous fee for his services ; but, concerning the 
nature of the accident, or of the ailment in question, there is little 
relative opportunity for him to deceive the sufferer or the friends. 
But when he is consulted in the case of a woman who is supposed 
to be ill with a sexual infirmity, the conditions are changed. He 
makes his diagnosis in the dark, as it were, and who shall dis- 
prove it ? His professional opinion is not open to criticism, nor 
his skill to a healthful competition. And hence the peculiar 
temptation, in this department of our calling, to those members 



656 THE DISEASES OF WOMEN. 

of the profession who have a bias towards dishonesty, and who 
seize upon every opportunity to make the most out of a class of 
eases which are often obscure, intricate and tedious at the best. 

Bennett and a host of lesser lights have decreed the uterine 
cervix to be the center of pathological interest in woman. Too 
many physicians make it the focus of pecuniary interest, and 
therefore punish it through personal cupidity and a lack of con- 
science, as well as of knowledge. 

Here is a poor woman whose local disease is the sign and seal 

of a constitutional cachexy. She is ill from her head to her feet. 

Her whole organism is deranged. A few little 

A constitutional and not • i , i i J j 1 iri 

merely a local disease. vesicles were 'developed upon the neck ol her 

womb. Their investing tunic was raptured, 
and an aphthous ulcer was the consequence. That ulceration has 
perpetuated itself, because the general condition from which it 
came has not been cured. A moment's reflection will satisfy you 
that cauterization is contra-indicated. For even if its effect were 
locally beneficial, and not injurious, it could do no good in a gen- 
eral way. The cause would remain, and the consequence would 
repeat itself. 

A more skillful, and successful method of cure in these cases* 
is to set about correcting the vitiated condition of the system, 

precisely as you would in a case of stomatitis 
'leiuh™^ the general materna. You may order a diet consisting 

chiefly of the nitrogenous principles. Beef, in the. 
form of steak or broths, oyster-soup, the whites of eggs, and 
milk, are preferable. To correct the strumous habit, the vegeta- 
ble acids are also necessary. Baked apples, peaches, grapes, 
oranges, or lemonade, are almost always grateful, and, I believe, 
useful in such cases. Where patients have foresworn tea and 
coffee, I have sometimes prescribed that they should resume their 
use, with a view to arrest the too rapid metamorphosis of tissue 
which is going on. 

For the first or vesicular stage of this disorder, and in old cases 

where a new crop of vesicles appear from time 

For the vesicular stage. ,. , - . , • ,• 

to time, cantharis, rhus tox., or aurum muriati* 
cum, are usually sufficient. 






APHTHOUS ULCERATION OF THE CERVIX UTERI. 657 

If there is also an aphthous condition of the mouth and of the 

alimentary mucous membrane, you may find it 

tion° r the aphthous condi " necessary to prescribe arsenicum alb., hyclrastin, 

mix vomica, belladonna, mercurius jod., or the 

nitric or sulphuric acid. 

Locally, I think it a good plan, in this form of uterine ulcera- 
tion especially, to use the same remedy that is administered inter- 
nally. It can be applied with water, or glycer- 

Local treatment. . t • i 

me, or both these substances as a vehicle. A 
very simple and available injection consists of adding a table- 
spoonful of glycerine to as much castile suds as will be needed 
for one application. In addition to the medicines already named, 
the coptis trifolia, borax, kali bichromatum, and of late years, the 
carbolic acid in weak solution, deserve to be mentioned in this 
connection. If the suppuration is very considerable, as it some- 
times is, calendula injections may be used with advantage. Where 
there is chronic vaginitis, with profuse leucorrhcea, and desquama- 
tion of the vaginal epithelium, whatever variety of injection is 
chosen, may be brought in contact with the entire mucous mem- 
brane of that canal through such an instrument as this, which is 
a cylindrical speculum, that is perforated with numerous holes of 
the size of a large shot. For the herpetic form of this disease, 
Leadam recommends the injection of a weak solution of the thuja 
oc, to be repeated two or three times daily. 

The objection to the topical use of astringents, as for example, 
tannic acid, alum, and the acetate of lead, in cases of this kind is 

that they do not possess any especial and spe- 

^Objections to astringents, cificaUy curative relatk)n t O the disease itself ; 

and also that they are extremely liable to cause 
such a modification of the circulation as shall tend to involve the 
menstrual function, and thereby to complicate the case. 

We will give Mrs. S arsenicum alb. 3, a dose three times 

daily. Her diet will consist of bread and milk with beef, potatoes 
and tomatoes, for dinner. Once each day she 
will drink a glass of good fresh lemonade ; and 
she will not let the day pass without going to walk or ride a lit- 
tle in the open air. She will also use the injection of castile suds 
and giyceriDe every night and morning.* 

*In four weeks this patient was well. She took no other remedies. 

42 



£58 THE DISEASES OF WOMEN. 



IRRITABLE ULCER OF THE UTERINE CERVIX. 

This form of ulceration is most frequently of local origin. It 
is is often chargable to maceration of the cervix i n the utero-vagv 
inal discharges, to the wearing of ill-adjusted pessaries, and to an 
excess of local treatment. For, much as they are imposed upon 
and persecuted, the cervical structures do sometimes resent such 
treatment, and take on an irritable state which is characterized 
by an excess of vascularity and sometimes by exuberant granula- 
tions. When this condition becomes chronic, there will be trou- 
ble elsewhere. 

Case. — Mrs. B , aged 40, has been ill for two months past. 

All her sufferings are referred to the epigastric region. She is 
subject to cramp-like pains in the pit of the stomach, which are 
sometimes so severe as to threaten her life. These paroxysms 
bear no relation to her meals, are not influenced by the variety or 
quality of her food, nor are they assuaged or aggravated in any 
manner by eating. They are quite as apt to return during the 
night as in the day. She has slight nausea, but no vomiting ; is 
very thirsty, and the bowels are costive. The tongue is pale but 
not coated, the lips are blanched, the oral mucous membrane looks 
as if it would readily become ulcerated, as in stomatitis materna. 
She is the mother of four children, the youngest of which is three 
years old. Has never had stomatitis. Has always menstruated 
regularly, but, for some months past, has observed that the flow 
is less free than formerly. She has no pelvic pain or distress of 
any kind, but is at times annoyed with a copious leucorrhcea, which 
she describes as purulent and very weakening. The discharge is 
increased by prolonged exercise, as by washing, or by walking a 
considerable distance. She has been treated for the gastric diffi- 
culty for some weeks past, but without the slightest relief. 

No physiological fact is more certain and more significant than 

the reflex relation which connects the uterus and the stomach. 

This relation is especially marked between 

Reflex relations of uterus $ie u terine cervix and the stomach. This poor 

and stomach. -L 

woman is the victim of utero-gastric irritation 
which is so decided as to make her wretched and to cause her 
a great deal of pain. But the pain and suffering are located 
exclusively in the epigastrium. From the mere symptoms which 
she has given us one would not be led to suspect any uterine com- 
plication. Even the leucorrhoea would not necessarily be due to 






IKRITABLE ULCER OF THE UTERINE CERVIX. 65i) 

ulceration. It might be catarrhal, and, at her age, critical in 
character, more especially as the quantity of the menstrual flow 
\s gradually diminishing. 

• In treating this class of cases in private practice it is not always 
advisable or necessary to subject the patient to an examination 
with the speculum. The better plan is to 
n eIe h s3ar P y e . culumnotalways remember these reflex relations, and to try if 
possible to cure the patient without placing a 
premium on the indiscriminate use of this means of diagnosis. But 
where the disease of the stomach, the heart, or any of the more 
important viscera does not yield to well-chosen remedies, you will 
be justified in proposing to search for the remote cause within the 
pelvis. And not unfrequently you will discover a latent and 
unsuspected lesion of some kind which will be quite sufficient to 
account, not alone for the peculiar nature of the individual symp- 
toms, but also for their persistency in not yielding to treatment. 

That there may be very extensive and serious disease of the pelvic 
organs, without a corresponding degree of suffering, indeed with- 
out the patient or her physician having sus- 
be T iatent terine lesi ° n may pected anything of the kind, is a fact beyond 
question. It is altogether probable that the 
ulcer which some members of the class saw in this case, in 
the ante-room just now, has existed from the commencement of 
this woman's illness. I have seen examples of the kind in which 
a similar lesion must have continued for months, and even for 
years, without being recognized. Such an oversight is quite as 
inexcusable as it would be to treat a patient's throat or lungs for 
months together without ever having made a physical examination 
of the parts affected. 

The surface of these uterine ulcers, in all such as are benign and 
not malignant, or specific in character, is usually covered either 
with pus, or with a bland, somewhat gelatinous 
iv?muc Va . lofthepr ° tect " mucus, resembling the white of an egg. These 
coatings are protective, and should be removed 
very cautiously, else the free surface of the ulcer may be 
wounded, and its appearance very much changed. If you will 
take a bit of cotton wool, or of soft sponge in the grasp of the 
forceps, pass the instrument carefully through the speculum, and 
when it approaches the cervix uteri, give it one or two. turns upon 



660 THE DISEASES OF WOMEN. 

its own axis, very gently and cautiously, you can wind the mucus 
about it in such a manner as to remove it from the surface of the 
ulcer without injuring it in the least. But if you mop it off 
roughly, your examination may be of little practical advantage, 
at least in so far as the differential diagnosis of uterine ulceration 
is concerned. 

The irritable ulcer is irregular in outline, and varies in its 

depth. It looks as if it had been cut out with a " punch," 

the base thereof being considerably depressed 

Appearance of the ulcer. ,,-,,■,■,«,■, , 

below the level 01 the mucous membrane 
covering the uterine cervix. This mucous membrane is some- 
times red, inflamed, and even cedematous, but again, as in this 
case, it is almost as colorless as cartilage. The bottom of 
the ulcer is of a dark red cranberry hue. Sometimes its vessels 
are so surcharged with venous blood as to cause it to be almost 
black in color. The granulations are very vascular, and bleed 
upon the slightest touch. Such patients sometimes complain of 
a slight flow of blood after exercise and after coitus. 

This ulcer implies a low grade of vitality. As in the case of 
irritable ulcers located on the shin, examples of which you have 
seen in the surgical clinic, it depends upon a morbid state of the 

general constitution, and a depraved habit of 
a sign of depraved vi- the patient. The digestive system is almost 

always deranged. The patient is badly nourish- 
ed. The mucous membranes elsewhere are not healthy, but 
pale, easily inflamed, and readily become ulcerated. This poor 
woman's lips and alse nasi confirm this view. They have a 
pearly, exsanguine look, and her tongue has the ragged appear- 
ance of one which has been badly ulcerated. The gums are not 
healthy, and there is every reason to suppose that the lining 
membrane of her stomach has participated to some extent in this 
tendency to inflammation and ulceration. Hence her indigestion, 
inanition, general ill-health, and uterine ulceration, which, with 
its consequent leucorrhcea, are increased sources of weakness 
and disease. 

But you must not suppose that this variety of ulceration is 

limited to the poorer classes of society. Indeed, 

Not limited to the poor. ,, .. » ,'. ,. 

the most marked examples ot this disease are 
sometimes met with among those who have " lived too well," 



IRRITABLE ULCER OF THE UTERINE CERVIX. 661 

bs the phrase is. These persons have brought on indigestion, 
and a depraved state of the nutritive function by eating irregu- 
larly and immoderately, by drinking too much wine and spirits. 
and developing an irritable, nervous temperament that has 
predisposed to this species of cachexia. It sometimes follows 
excessive loss of blood, as in haemorrhage from abortion, and 
may be due to too prolonged lactation. 

Treatment. — When there is reason to believe that uterine 
ulceration proceeds from, or is perpetuated by some digestive 
derangement, it is of the first importance to 
.DSTetc. he indigestIon ~ correct that disorder, whatever it may be. 
For this purpose the diet should be carefully 
prescribed, such aliment being chosen as can be most readily 
•digested and assimilated. Albuminous articles are preferable. 
Lean meats, milk, the white of eggs, oysters and fish in their 
season, good bread, rice and farinaceous food, afford a sufficient 
variety. Fruits will furnish the vegetable acid, which is some- 
times an excellent antidote to this cachexia. In case of indi- 
gestion, peaches, apples, pears and cherries should be cooked 
before eating them. This is especially true if they must be 
procured from the market. 

It is also desirable in this class of cases to husband the re- 
sources of the patient's system as much as possible, by closing 
any drain which may be exhausting her little 
stock of strength. Haemorrhage, too excessive 
or prolonged lactation, diarrhoea, leucorrhoea, night sweats, copious 
expectoration, or diuresis, may need to be remedied before you 
prescribe for the ulceration itself. Fresh air, sunlight, diversion 
of the mind, and the cultivation of a good morale, are as requisite 
here as elsewhere. 

The class of remedies most frequently indicated are arsenicum 
-alb., nitric, muriatic or sulphuric acids, sulphur, rhus toxicoden- 
dron, baptisia tinctoria, hydrastin, and arseni- 

Internal remedies. , . 

cum jod. Incidental remedies may be given 
for incidental symptoms, but we can not be very far wrong in 
prescribing the first of these for Mrs. B. She will take a dose 
of arsenicum alb. 6th, morning and evening, and report on our 
next clinic day. 

But it is not sufficient merely to regulate the diet, the exercise, 



662 THE DISEASES OF WOMEN. 

and the hygienic condition and surroundings of this class of 
patients. Some kind of local treatment is 

Local treatment. ■ 

called tor, and may, it properly selected and 
applied, assist in the cure. Although, as I have already said, 
Nature extemporizes a coating for the ulcerated cervix uteri, 
still that coating is not always sufficiently protective to prevent 
the contact of the atmosphere and of acrid discharges, which 
may serve to interrupt the healing process. And although it is 
in a measure protective, that mucus is not properly, or in any 
sense curative. Therefore we find it advisable and necessary to 
substitute this natural covering by a better one, one that shall 
serve to keep the part protected against harmful influences, and 
which is, at the same time, possessed of healing properties. You 
may sometimes apply the baptisia, calendula, hydrastin, or, if you 
prefer, the same remedy which you have ordered to be taken in- 
ternally. Simple glycerine will sometimes be sufficient. When 
either of these substances are given by injection, the vagina 
should first be syringed out thoroughly, in order to remove foreign 
matters, mucus, etc. After taking such an injection, the patient 
should lie upon the back, with the hips elevated, and without 
moving the body or shoulders for a considerable time. These 
injections may be repeated twice or thrice daily, according to cir- 
cumstances. Where the leucorrhceal discharge is purulent and 
copious, as in this case, I prefer the calendula with glycerine. 

In this case the near approach of the climacteric may interfere 
somewhat with a prompt and radical cure of the ulceration. For, 
although all forms of uterine ulceration heal more slowly and less 
certainly at the change of life, you will find the irritable ulcer 
especially liable to become chronic, or, if healed up, to break out 
again. 

I have long been satisfied that a special source of mischief in 
these cases, and one reason why they resist our remedies and re- 
lapse, is to be found in the condition of the rectum which permits 
the absorption into the pelvic circulation of certain fsecal matters. 
This induces the form of blood-poisoning that has been described 
by Dr. Barnes under the head of copramio, which has the effect 
to interrupt the healing process in cases of irritable nicer especi- 
ally. To overcome this condition we must correct the habit of 
constipation, and, if necessary, have the rectum cleansed every 
day. 



DIFHTHERITIC ULCERATION OF THE OS UTERI. 663 



DIPHTHERITIC ULCERATION OF THE OS UTERI. 

In this variety of uterine ulceration the constitutional symp- 
toms correspond with those which are present in diphtheria, affect- 
ing other portions of mucous membrane, as for 

Constitutional symptoms. , . 

example, the nasal and respiratory passages. 
There is the same evidence of blood-poisoning, the same prostra- 
tion and attendant phenomena, and the same sequelae that occur 
when the throat is the seat of the abnormal deposit. 

Examination per vaginam reveals an ulcer upon one or both lips 
of the cervix, which is covered, or nearly so, with a heterol- 
ogous deposit. This deposit or pseudo-mem- 

Physical symptoms. ' . . 

brane is a ioreign growth, which, m due time, 
exfoliates. In some cases instead of one or two large-sized 
ulcers, there are a number of small, whitish, shining patches, 
which vary in size from that of a split pea to half a hazel-nut. 
These patches may, or may not, coalesce. To the " touch' ' they 
impart a rough or dry sensation that is quite peculiar, and very 
different from the feel of other ulcers. 

The pseudo-membrane which covers the diphtheritic ulcer, or 

patch, is at first very adherent, and cannot be detached without 

more or less injury and consequent haemorrhage. 

The pseudo-membrane. ft i--ii t n • • 

Atter a little while, however, the friction of 
the parts during the motion of the body, as in walking or sitting 
upright, or a careless introduction of the finger, or of the specu- 
lum, may separate them. Their removal leo.ves a raw, bleeding, 
painful, intractable, suppurating ulcer, which may, or may not, 
extemporize another wash-leather covering for itself. According 
to Becquerel, in the order of their coming, the formation of these 
false membranes precedes the development of the ulcer, or diph- 
theritic chancre. It is only while something of the covering 
remains that these ulcers can be diagnosticated with absolute cer- 
tainty. 

As a rule the larger the surface of the diphtheritic ulcer, the 

more superficial it is ; and per contra, the 
and h he d dSc h hrr f 4 he uker ' sm aller its dimensions, the greater its depth. The 

deeper the ulcer, the more profuse the discharge. 
Sometimes the flow therefrom is acrid and corrosive, and as in 



HGl: THE DISEASES OF WOMEN. 

nasal diphtheria especially, it destroys, or perhaps inoculates the 
adjacent tissues. This discharge is always fetid, and, when it is 
obtained directly from the ulcerated surface, emits the peculiar 
diphtheritic odor. True diphtheria may be produced in other per- 
sons by inoculation with this virus. 

Diphtheritic ulceration of the os uteri is rarely an idiopathic 

affection. The throat and other parts are generally first attacked, and 

afterwards the vulva, vagina and neck of the 

A secondary disease. . ,.,.., 

womb. As m syphilitic ulceration, the superior 
vagina and cervix are less frequently the seat of the lesion than 
are the inferior vagina and the vulva. It has been remarked that, 
as in other forms of diphtheria, this species of uterine ulceration 
is especially liable to occur during the epidemic prevalence of va- 
dola, rubeola and erysipelas. Many obscure affections of the gen- 
erative system have undoubtedly resulted from prolonged exposure 
to diphtheria, and the fatigue of nursing those who were ill with 
that disease. In these cases the utero-vaginal mucous membrane 
has probably been the seat of diphtheritic inflammation and ulcer- 
ation, where nothing of the kind was suspected. 

If the diphtheritic ulceration of the os and cervix uteri takes 
place during pregnancy, it is very likely to cause abortion ; if 
during the lying-in state, it may invade the uterine cavity, in 
which case pseudo-membranous patches have been found at post 
mortem lining the uterus itself. 

Dr. Tilt reports a case in which he claims that a patient had a 

diphtheritic ulcer of the os uteri from leech-bites. But, in order 

to produce a generic ulcer of this kind, it is 

Cause. , . n 

necessary that the specific cause should be at 
work. For this specific agency, whatever it may be, is just as 
requisite in this case as it is in diphtheritic angina or conjunctivitis. 
The only cases of diphtheritic ulceration of the os uteri and the 
vagina which I have seen have occurred in the persons of those 
women who, from watching and taking care of those who were ill 
with diphtheria, became predisposed to this form of the complaint 
and took it in this way. It is possible, and even probable, that 
some previous disorder of the generative system, in each of these 
cases, may have caused the lesion to locate itself upon the uterus 
rather than in the throat. During the prevalence of an epidemic 



POST-PARTUM ULCERATION OF THE WOMB. 6G5 

of diphtheria you should examine this class of patients very care- 
fully with the speculum. 

The treatment need not differ essentially from that proper foi 
other forms of diphtheria. If any one remedy deserves more 
prominent mention than another, it is cantharis. 
And this not only because of its frequent indi- 
cation in the treatment of other varieties of diphtheria, but also 
on account of its special curative relation to the cervix uteri. 
Mercurius jod., kali bich., kali brom., phytolacca, nitric acid, 
jodium and hepar sulphuris may be of great service under their 
especial indications. 

Locally, injections of the tincture of hydrastis, or calendula, or 
of any of the aforenamed remedies, diluted with water, or glycer- 
ine, or both, are sometimes very serviceable. 
If the discharge is very fetid and offensive, the 
chlorate of potash, in the proportion of half a drachm to four 
fluid-ounces of distilled water, and used in the same manner, an- 
swers a good purpose as an antiseptic. And so also does a weak 
solution of carbolic acid, of kreosote, or of the permanganate of 
potash. The objection to the potash salt is on account of its 
color. My friend, Dr. W. H. Holcombe, has made use of the kali 
bichromicum, in the strength of half a grain of the crude drug 
dissolved in a tumbler of water, " as an injection for ulcerated os 
uteri, and even for leucorrhcea, with sfood effect." This may also 
be used for the relief of diphtheritic ulceration and of vaginal 
diphtheritis. 

Since this form of uterine ulceration is inoculable, like the 
syphilitic variety, it is important to exercise the proper care in 
the use of instruments, napkins, etc., lest we 
carry the disease to other patients who may hap- 
pen to be under treatment for various uterine affections. There 
is also the same need for isolation in diphtheritic ulceration of 
the womb as in diphtheritic sore throat. 

POST-PARTUM ULCERATION OF THE WOMB. 

Although ulceration of the womb is not usually classed among 
the sequelae of labor, there is little doubt but that it sometimes 
occurs in this connection. 

Case. — Mrs. , aged 28, has an infant five months old. She 

nurses the child, which is thrifty, and lives exclusively upon the 



6Q6 THE DISEASES OF WOMEN. 

breast. The mother is not well. She has not menstruated since 
her confinement. She complains of aching in the loins, weariness 
on very slight exertion, pain in the left iliac region, with inability 
to lie upon her left side, malaise, anorexia, frequent headache, 
occasional strangury, and a leucorrhcea which at times weakens 
her very much and increases the old pain in the back. These 
symptoms began during her lying-in, and have continued until 
now. 

An examination with a speculum discloses a simple suppurating 
ulcer within and around the external os uteri. 

When uterine ulceration occurs in women who have but recently 

been confined, it is very apt to be overlooked. The patient may 

have escaped the perils of childbirth, but for 

Likely to be overlooked. 

some unknown reason she has a lingering con- 
valescence. At first there may have been a considerable degree 
of puerperal inflammation, and following this a state of things 
analogous to what Trousseau styles " colliquative suppuration/' 
Lactation, is, perhaps, normal, and the other functions are intact, 
but she is extremely weak and reduced, and rallies but slowly. 
A month or two may have passed before she is able to make an 
excursion to the dining-room, or the parlor, and three, or even 
six months before she can take a drive. Meanwhile she has lost 
her accustomed elasticity, and life is become a burden. She 
drags around, impelled by circumstances, and the probabilities 
are that her ill health will be charged to some other cause than 
the ulceration, which dates from the birth of her child. 

In such a case the lesion of the os is undoubtedly a result of 
the inflammatory process. After delivery the uterine tissues 

readily become inflamed. This inflammation is 
tic£ sequd ° f inflamma " often, but not always, of such a low grade and 

type as to develop into ulceration. And once 
the ulcerative metamorphosis is begun, it is likely to be overlooked 
and perpetuated. It is altogether probable that pressure upon 
the cervix, and traumatic injuries thereof during the labor, may 
indirectly occasion such symptoms as those of which our patient 
complains. 

If there were anything distinctive in these symptoms, they 
would be more easily and generally recognized. But, in a given 
case, we cannot know positively that a lesion of the cervix exists 
without ocular examination. Here the speculum is as requisite a 



F0ST-PARTU3I ULCERATION OF THE WOMB. 667 

means of diagnosis as if the disease were idiopathic, and did not 
follow parturition. 

There are two general causes for this species of uterine ulcera- 
tion, or, rather, for ulceration of the cervix, occurring in women 
at this particular period. The first is the drain 
bbUi paired quaUty ° f th ° u P on the mother's blood during gestation ; and 
the second, a similar drain through the mam- 
mary glands while she is nursing. By impairing the quality of 
the blood, and thus lowering the grade of vitality, these causes 
increase the risk of post-partum inflammation. And in such 
depraved states of the system there is but a short step from 
inflammation to ulceration of the uterine neck. The same remark 
applies to ulceration as a sequel of abortion, more especially after 
the fourth month. 

Treatment. — The hint which I have just given 3^011 concerning 

the relation between the depraved and impoverished condition of 

the blood and the symptoms complained of, is 

Weaning the child . . 

01 great practical significance. Acting upon 
it, you would prescribe the proper hygienic regulations. If you 
are satisfied that there is too much of waste and expense to the 
mother's organism in the quantity of milk that she furnishes, it is 
better to feed the child with something else than to bankrupt the 
mother's strength in this manner. Weaning is a last resort. It 
is not necessary, except in extreme cases, and where the quality 
of the milk is such that the child is finally poisoned by it. 

The diet should be as nourishing as possible. Allow milk, lean 
meats, eggs, game, fruits, and good bread and butter, instead of 

the sick-room teas, slops and kindred abomina- 

Thediet. . ' L 

tions. Fresh air and sunlight should also be 
ingredients in the prescription. But let me caution 3-ou to re- 
member that walking may be very harmful, in case of uterine 

ulceration, and for this reason, the womb beinGr 

Walking. . ' ' ° 

pendulous when the patient walks, the denuded 
cervix is brought into contact with different portions of the vagi- 
nal mucous membrane. Friction irritates it, and excites the local 
circulation to such a degree as greatly to increase the suffering, 
and to extend the lesion. Moreover, the blood gravitates into 
the pelvic organs, and the consequent congestion more than 
counterbalances the good effect of the out-door air and exercise. 



()QS THE DISEASES OF WOMEN. 

Riding is less objectionable, but I have observed that many patients 
with uterine ulceration complain seriously of 
the street-cars, the stopping and starting, as 
well as the roughness of which, worry them more than riding in 
the stages on the avenue, or in a private conveyance, if it be 
carefully driven. You would not send such patients to ride in a 
rough country wagon, neither upon horseback. 

Compared with ordinary cases of uterine ulceration, the post- 
partum variety may be more easily and promptly cured. The 
explanation of this fact is to be found in the ex- 
andwhy° mparatively easyi emption of the menstrual return, which so much 
retards the cure under different circumstances. 
Here is no periodical determination of blood to the womb. In 
lieu thereof we have a physiological afflux of blood to the mam- 
mary glands, which is really derivative in its influence upon the 
intra-pelvic organs. For this reason, the proper treatment should 
not be deferred, else the menses will re-appear, and the cure be 
very much delayed in consequence. 

It sometimes happens that the too early return of the menses in 
one who is nursing is an evidence of debility and of waning 
strength. It may signify that the mother's force 
tadon nstruati ° ndurInglac " and vitality are fast ebbing away. Much will 
depend upon a proper interpretation of the 
symptoms in such a case, and upon the line of treatment which 
you adopt. 

There are those who insist upon the necessity of cauterization 
in every form of uterine ulceration. They cannot divest them- 
selves of the idea that such lesions are removed 
indiscriminate and exciu- f rom ^he sphere of influence of internal reme- 

sive local treatment. I 

dies. They argue, and with some show of rea- 
son, that there is a lack of responsiveness on the. part of the tis- 
sues w^hich compose the uterine cervix to the best selected consti- 
tutional treatment. Some even go so far as to insist that no such 
ulcer can be healed except by topical applications, among the best 
of which are the various escharotics. 

But many physicians are in the habit of treating ulceration of 
the mucous membrane and of the integument by means of internal 
remedies exclusively. The various forms of stomatitis, ulcerated 
sore throat, chronic laryngitis, and bronchitis, typhoid fever, 



POST-PARTUxM ULCERATION OF THE WOMB. 669 

chronic enteritis, typhlitis and dysentery, yield to this method of 
medication. If in any of the three former affections they consent 
to apply the caustic, it is an exceptional case ; while, in the latter, 
it would be altogether impracticable to do so. 

A large proportion of cases of external ulcer need nothing more 

topically than to be protected from the irritating influence of the 

atmosphere by some bland and harmless appli- 

Only specific ulceration . ' 

needs specific local treat- cation. In some cases we may facilitate the 
healing process in them by the local use of the 
same remedy that is given internally ; but, excepting in specific 
ulcers, not one in a thousand of them needs cauterization. So in 
ulceration of the os uteri — when there is no specific reason, either 
in the nature of the lesion, or in its cause and symptoms, why some 
specific remedy, as for example the nitrate of silver, or iodine, or 
what not, should be applied locally, your good sense and judgment 
would dictate their prohibition. 

It has been argued in advocacy of the indiscriminate local treat- 
ment of uterine induration and ulceration, that a spontaneous cure 
thereof was impossible, because of the frequent 

Arguments pro and con. . 

return and concomitants ot the menstrual now, 
the dependent position of the uterus, and the evil consequences 
of sexual excitement. But it does not follow that, because these 
cases do not get well of themselves, therefore they all need to be 
cauterized. It is bad practice to prescribe at wholesale. 

In the case before you the menstrual aggravation is not present. 
The peculiar position of the womb does not so strongly predispose 

to its vascular derangement, or to the perpetua- 

Interdiction of coitus. . n 1 

tion ot a chronic lesion unless the woman men- 
struates, or its tissues are undergoing the changes which are proper 
to gestation. In serious cases of ulceration of the womb, the 
worst consequences may follow a frequent repetition of the sexual 
act. Such a patient should live apart from her husband. A large 
share of the benefit attributed to the local treatment of uterine 
ulceration by caustics of all kinds should really be ascribed to the 
necessary interruption of the marital intercourse, which is thus 
rendered impossible. The same is true, but in a qualified sense, 
of the advantage claimed for change of air, etc., by those who 
leave their homes and husbands behind them, to seek for treatment 
elsewhere. 



670 THE DISEASES OF WOMEN. 

You will not understand me as objecting to every variety of 
local application in simple ulceration of the os uteri. Such an ex- 
treme view would be as untenable as that which 

Allowable local treatment. -. 

holds that such means, and only such, are abso- 
lutely requisite and curative. There is no valid objection to the 
topical employment of diluted glycerine, with or without the cal- 
endula, of sweet oil, or of the oleaginous collodion in the case of 
this poor woman. Either of these substances will be grateful to 
the diseased part, will serve to protect it from the injurious effects 
produced by contact of the vaginal mucus and the leucorrhceal 
discharge, and will also stimulate the reparative process whereby 
the lesion can be healed. The calendula is especially useful where 
the purulent or muco-purulent flow, as in this case, is very con- 
siderable. It may be used as a vaginal injection morning and 
evening. 

The internal remedies that may be required will vary with the 
symptoms presented in each individual case. Chief among them 
are calendula, calcarea carb, arsenicum, sepia and sulphur. 



LECTURE XLI. 

LEUCORRHOEA WITH CHRONIC OVARITIS. 

General remarks on leucorrhoea. Leucorrhoea with chronic' ovaritis. Chronic leucor- 
rhoea and the scrofulous dyscrasia. Irritable uterus or hysteralgia. 

Although leucorrhoea is a symptom and not a disease per se, we 
are so often called upon to prescribe for it that it may be expedient 
to consider it briefly in the two cases which I shall show you this 
morning. Both of them are secondary and symptomatic, and in 
this light they are typical. The first is dependent upon chronic 
ovaritis, and the second upon a very different cause. Leucorrhoea 
may also be a critical and therefore a salutary affection, and for 
this reason it is not always best to seal it, whether by local or 
general means. If a flow of this kind follows the menstrual period 
it may be prophylactic of ovarian and uterine inflammation. 
Cases of laceration and of sub-involution of the uterus are almost 
as certain to be accompanied by leucorrhoea as they are by menor- 
rhagia and prolapsus. 

Case. — Mrs. , aged thirty, was married seven years ago, but 

has had no children, and has never suffered a miscarriage. She has 
had leucorrhoea for the last ten years. The discharge is of a 
yellowish white color, sometimes thick and creamy, and again 
thin, copious, and quite fluid. After having been upon her feet for 
a long time, the flow becomes more profuse. She is certain that 
the quantity discharged frequently amounts to three or four ounces 
in a day. When the matter which is most liquid escapes, she feels 
most exhausted. She complains, at such times especially, of a 
sense of weariness, and of dragging pains in the loins and hips. 
For a lono; time, she remarked the leucorrhceal discharge was 
most profuse either immediately before, or directly after, her 
menstrual "returns;" but tor some time past she could discern no 
especial increase at this or any other period of the month. 

She menstruates regularly every four weeks, but the proper flow 
is gradually lessening in quantity, so that at present she is "sick" 
but two days instead of three, or three and a half, as hereto- 
fore. The only suffering experienced during menstruation is a 
severe, burning pain, which is located just within the anterior 

671 



672 THE DISEASES OF WOMEN 

superior spinous process of the left ilium and above the groin, or 
in other words, in the region of the left ovary. This pain, which 
is sometimes very severe, always extends down the corresponding- 
thigh to the knee. She has never had it upon the right side. She 
is quite confident that she has not menstruated a single time, dur- 
ing the last ten or twelve years, without experiencing this peculiar, 
burning, cramp-like, neuralgic pain. When the catamenia cease,. 
it immediately declines, and she has never had it in the inter-men- 
strual period. Riding and walking increase its severity. 

Examination by the speculum discloses a scrofulous suppurat- 
ing ulcer at the os externum, extending into the canal of the 
cervix. The mucous membrane, investing the vaginal portion of 
the uterine neck, is considerably swollen and congested. The left 
ovarian region is exceedingly sensitive to external and internal 
palpation. She has been treated by four physicians, three of 
whom cauterized the cervix severely, but without any benefit to 
the patient. Indeed, she steadily continued to grow worse, and, 
as you see, her general health is now very much impaired. 

A chief point of interest in this case is the lesion of the left 

ovary and its consequences. For, the local symptoms which occur 

so regularly, are so characteristic and so constant 

Burning pain in ovaritis. 

ovulation sometimes a that we are iorced to conclude that the ovarian 

constant cause of ovaritis. m . 

disease is the primary one. There is, indeed, 
something quite distinctive about this " burning " pain in the 
inguinal region, which extends down the limb of the same side. 
When it comes on with the return of the catamenia, and ceases 
during the inter-menstrual period, you may be certain that the cor- 
responding ovary is inflamed. This inflammation may exist for 
years, with a brief, sub-acute and self-limited attack each month. 
The cause of this fresh and painful recurrence of inflammation is 
the physiological afflux of blood to the organ ; without this afflux 
the proper function of the ovary can not be performed, any more 
than the gastric juice can be secreted if the delicate capillaries of 
the gastric mucous membrane are not injected with blood. It is 
the periodical repletion of the vessels of an inflamed ovary that 
gives rise to the peculiar, burning, cramp-like, neuralgic pains of 
which our patient has just made complaint, and that has literally 
been the thorn in her side for these many years. 

The reflex relations of the ovaries are numerous, varied, and 

Reflex relations of the important. They are in sympathy with the 

ovary " lungs, the mammary glands, the uterine mucous 

membrane, the nerve centers of animal life, and especially with 



LEUCORRHCEA AVITH CHRONIC OVARITIS. 67o 

the uterine cervix and its secretory apparatus. The neck of 
the uterus is not more intimately associated with the womb 
itself, of which it is the natural outlet, than it is with the 
ovaries. These little organs, although remotely located, have 
really as much to do with the active dilatation of the os uteri, and 
the escape of the menstrual flow through it, as they have with its 
first formation in the uterine cavity. They not only serve as 
time-keepers for the menstrual organism, but they also open the 
gateway of the generative intestine for the escape of its periodical 
discharge. 

This peculiar sympathetic function is exceedingly liable to 

derangement. In a state of health, both of the ovaries and of the 

cervix, it is intact. But suppose that either of 

Sympathy between the 

uterine cervix and the these parts becomes the seat oi serious and pro- 
ovaries. -I -i . . . 

tractea disease — nothing is more certain than 

the consequent, although indirect, implication of the other. It 
would be almost, or quite impossible for our patient to have had 
this form of sub-acute ovaritis for so long a period without the 
cervical leucorrhcea also. Protracted and persistent leucorrhceal 
discharges, whether from the uterus or the vagina, or both to- 
gether, are always indicative of structural disease somewhere. 
The lesions which produce them may b idiopathic or secondary. 
They may depend upon causes which are purely local, upon those 
which are constitutional, or upon such as are reflex. In the case 
before us there is little doubt that the ulceration depends on the 
inflammation of the left ovary, which is the fount and origin of the 
disorder for the relief and cure of which we have been consulted. 
The gradual diminution of the menses is significant and sug- 
gestive. When ovaritis is accompanied by uterine ulceration, 
which is not cancerous or phagedenic, there is 
Leucorrhcea may substi- a l m ost alwavs a tendency in the menstrual 

tute menstruation. J J 

secretion to become more and more scanty. 
Under these circumstances, the leucorrhcea sometimes substitutes 
menstruation, when it is termed " vicarious." This result is more 
likely to follow the inflammation of both ovaries than of one. 
In catarrhal leucorrhcea, without ulceration of the cervix, and 
uterine and vaginal ca- whether it comes from the uterus or the vagina, 
tarrh from ovaritis. ^q discharge is usually increased either before 

or directly after the catamenial flow. Here the ovarian sympa- 

43 



674 THE DISEASES OF WOMEN. 

thy spends, itself- in giving rise to an extraordinary secretion of 
mucus, and menstruation is more apt to be profuse than scanty. 
Some of the worst forms of menorrhagia, or excessive menstru- 
ation, are engrafted upon this kind of leucorrhcea, which may 
also arise from ovarian irritation and inflammation. 

Sterility is a natural and almost necessary consequence of either 

of the forms of leucorrhcea just named, which 

le^rrhffia 55 ° aused by might, without any great impropriety, be styled 

ovarian leucorrhcea. As our patient's disease 

commenced before her marriage, there are the best of reasons why 

she has never been pregnant. 

Treatment. — It is possible that enough has already been said to 
illustrate the importance of a correct knowledge of special pathol- 
ogy in cases of this kind. And yet I must 
iai T P h a e thSSgy ance ° f spec ~ embrace so favorable an opportunity to say a 
few words upon a subject concerning which you 
will find so much in our books and journals. I apprehend that no 
man or woman ever yet made a prescription without having in his 
or her mind a theory of the ailment to be treated. However 
improperly it may have been done, the simplest domestic remedy 
is not given until the disease has been classified. And among the 
fraternity, nolens volens, we are as much addicted to the habit of 
naming diseases before we treat them, as to the naming of our 
babies before they are baptized. And because this theory, which 
represents our idea of the special pathology of the disease in ques- 
tion, and typifies our knowledge or our ignorance of it, is "as 
inevitable as one's shadow," it is vitally important that it be cor- 
rectly established. If we would unravel the tangled skein, we 
must get hold of the proper thread. In order to be skillful and 
successful in the interpretation and cure of diseased states, we 
must begin at the right end of the series. 

According to the theory that the ulceration gave rise to the leu- 
corrhcea, and that what would heal the former would also cure the 
latter, this patient has been cauterized by three physicians in turn. 
Their applications may have patched up the case, but, for reasons 
which you now understand better than they seem to have done, 
the cure was not permanent. The lesion of the os reappeared, 
simply because the ovarian affection had been overlooked and neg- 
lected. And not only did the cruel expedient to which they 



LEUCORRHCEA WITH CHRONIC OVARITIS. 675 

resorted fail to cure the lesion of the os uteri ; it also increased 
the ovarian congestion and inflammation. For the sympathy be- 
tween the cervix and the ovaries is such that whatever harms 
one will almost certainly implicate and injure the other. 

Your preceptors are fully aware of the fact that a large share of 

the ovarian affections which they are called upon to treat have 

been caused in this manner. And your own 

indiscriminate cauteri- f u ture experience will one day confirm the 

zation of the os uteri. -L «/ 

observation, that the indiscriminate employment 
of escharotics in uterine ulceration is mischievous to the last 
degree. If those three doctors had been more competent diag- 
nosticians, they would have been less likely to commit such an 
unpardonable error in practice. 

Let us endeavor to improve upon this treatment. We must 
study this case most carefully, not for the purpose of naming the 
disease, and afterwards treating it by name, for that plan has 
already been tested ; but to analyze the symptoms presented, and 
to remove them in the most rational and sensible manner. In a 
case of this kind the ovarian symptoms are a thousand times more 
significant than those which pertain to the leucorrhceal discharge. 
The proper plan is, therefore, first to treat the disease of the left 
ovary, and afterwards, if anything remains of the uterine ulcera- 
tion and its consequent discharge, to address our remedies specifi- 
cally to them. 

The prominent symptoms for which we must select a remedy in 
this case are, therefore, severe j)ain in the left ovaiy, which is of a 
"burning character, extending down the corresponding limb, which 
recurs with every return of the catamenial period, and is aggra- 
vated by riding or walking ; the menses become more scanty, and 
are accompanied and followed by leucorrhoea. The appropriate 
remedy is thuja oc, of which she will take a dose every evening 
during the month. 

The most proper and effective treatment in cases of this kind is 

one that is brought to bear during the inter-menstrual period. 

Palliatives and kindred expedients, only de- 

Inter-menstrual treatment. . 

signed to relieve suffering while menstruation 
continues, are in no sense curative. The persistency of the symp- 
toms just named, and the unequivocal indication presented for the 
thuja, warrant us in promising a great, although it must be a 



676 THE DISEASES OF WOMEN. 

gradual, improvement in our patient's health. In addition to the 
internal remedy, she should syringe out the vagina twice daily 
with tepid castile suds. In some cases of this kind I add a few 
drops of the crude tincture of thuja, and in others of calendula, 
to the water injected into the vagina. But it should be an indict- 
able offense, for the physician to prescribe or apply astringent 
washes and escharotics, for the relief of such a case of leucorrhcea 
as that to which your attention has now been called. 

You will not understand me to recommend this prescription for 
all cases of ovarian inflammation indiscriminately. Before the ses- 
sion has closed, I shall doubtless have occasion to advise the em- 
ployment of various other remedies in the treatment of this 
disease. 

CHRONIC LEUCORRHCEA AND THE SCROFULOUS DYSCRASIA. 

Case. — Mrs. V., aged 36 complains of a chronic leucorrhcea which 
she has had for years, indeed it has been more or less constant since- 
puberty. She has three children, and says that she has no exemp- 
tion from this discharge during pregnancy. Her youngest child, 
which she continues to nurse, is thirteen months old. The quantity 
of the leucorrhoeal flow is large, and has always been so, excepting 
while she suckled her children. She always had a copious secretion 
of milk " enough for two babies instead of one." She is slender and 
delicate, takes cold very easily, and is subject to severe attacks of 
diarrhoea, which, together with the leucorrhoeal flow, weakens her 
very much. There is no especial aggravation of her symptoms at 
the month, or at any other time. The menses are regular, but 
rather copious. Her family are scrofulous, one of her brothers 
having had "a white swelling," and a sister having had numerous 
abscesses of a scrofulous character. 

For practical reasons, it is well to divide the varieties of leucor- 
rhcea into the acute and the chronic forms. Acute leucorrhcea may 

be physiological, critical, and even salutary, as 
crmcaT rhCeamaybe spermatorrhoea may exist without being, in a 

proper sense, pathological. A leucorrhoeal flow 
sometimes affords a means of escape for an excess of serum that 
has accumulated within and about the glandular structure of the 
cervix uteri, and which has been attracted or driven thither by some 
temporary local excitation, or reflex emotional cause. Like a 
perspiration, or a free diuresis, it may be designed to open a safety- 
valve in order to prevent a local congestion or inflammation* 



CHRONIC LEUCUIJRHCEA, ETC., 677 

Such a flow may be critically prophylactic of bronchitis, a fit of 
indigestion, a diarrhoea, or an attack of " sick-headache." As my 
friend, Prof. Sanders has shown,* it may furnish a means of 
elimination and of ready exit for morbid products that would be 
mischievous if they were retained. Or it maybe contingent upon 
some slight menstrual irregularity, a temporary displacement of 
the uterus, functional disorders of the bladder or of the rectum, or 
upon an irritation of the mammary glands, or of the ovaries. But 
if it is acute, it is more likely to be salutary than harmful. And in 
every such case, provided we do nothing to increase the difficulty 
or to prolong its duration, it will cease of itself as soon as its 
transient exciting cause has been removed. 

When, however, as in this case, a leucorrhcea becomes chronic 
or habitual, when it has persisted, without cessation, for weeks or 
months, draining away the patient's strength, 
pa ^ landffenerai making her wretched, one of three things is 
certain : ( 1) either there is some local cause, near 
or remote, which gives origin to the disease, and sustains it ; or (2) 
there is a bad habit of body, a depraved condition of the general 
system, a cachexia, a morbid bias, or a dyscrasia, inherited or 
acquired, which perpetuates it; or (3) these two sets of causes are 
combined. 

Perhaps we should approximate the truth most nearly by as- 
suming that, of all the cases of leucorrhcea that have come to our 
individual notice, one-third of them were of the acute, or self- 
limited kind; another third were intimately connected with the 
history of some local lesion, or lesions, of the generative apparatus ; 
while the remaining third were essentially of a constitutional 
character. But the physician who is engaged in a general prac- 
tice will find these proportions to vary considerably. It may 
happen that only the first class of cases will fall under his care. 
This is especially true in the cities and larger towns, where the 
more serious and protracted examples of female disease, of what- 
ever variety, are placed in the care of the specialist. Hence it 
would not be strange if the general practitioner 
anI a -esufts 1UflUenC S snou ld draw a wrong inference concerning the 
results ot his experience, or the universal efficacy 
of his particular method of treatment. If, for example, he had 

* Vide Transactions of the Twenty-sixth Session of the American Institute of Homoeo- 
pathy, page 490. 



678 THE DISEASES OF WOMEN. 

relied exclusively upon internal medication, basing the choice of 
the remedy upon the indications which are ordinarily given, and 
the result was favorable, he might conclude that nothing else 
would be required in any possible case of this kind. 

On the other hand the specialist, who sees a much larger pro- 
portion of cases of leucorrhcea which belong to the second group, 
is almost certain to adopt the current theory that there is always 
a local lesion at the bottom of the difficulty. To him a leu- 
corrhceal flow is synonymous with inflammation and ulceration 
of the uterine cervix, and it is difficult to persuade him that any- 
thing excepting an escharotic will cure it. Or, if it is ail excep- 
tional case, and he is sufficiently discriminating to exclude these 
lesions as the cause of the trouble, it is altogether improbable that 
he would depend upon any other than surgical means for its relief. 
The conclusions, therefore, are founded upon peculiar and indi- 
vidual experience both with respect to the variety of cases in 
which the doctor has been consulted and the apparently uniform 
success of the exclusive treatment which he has employed. 

It is not difficult to discern, therefore, that, while these parties 
may be equallv honest, both are deceived as to the facts in the 
case. For each has been working in a hemisphere, and neither of 
them has made the whole circuit of the question at issue. 

Generally speaking so little is thought of the constitutional 

causes or modifications of this affection that they are regarded as 

of little consequence in its treatment. Especi- 

Constitutional causes. n . .,. . „ . , -. . i • i t 

ally is this true ot those dyscrasire which under- 
lie and complicate it, and which because they are latent and 
obscure, are apt to be overlooked and ignored. 

Without any disposition to magnify the importance of this class 
of causes, or to construct a predetermined rule, or system of 
invariable practice, in the treatment of this or of any other disease, 
I shall remind you of the influence which one of these morbid 
states of the constitution exerts upon the clinical history of leu- 
corrhcea. 

Whatever the differences of opinion among medical men con- 
cerning the existence of scrofulosis 'as a distinct disease, it will be 
conceded that it represents a faulty state of the 
general health which often predisposes to, and 
alters the clinical history of other diseases. Its modifying in- 



CHRONIC LEUCORRHCEA, ETC. (579 

fluence over affections of the skin, and oi the mucous membranes 
especially, is well known. There is nothing new in this very 
general idea; but when applied to the etiology, pathology and 
treatment of leucorrhcea, its practical lessons are scarcely recog- 
nized by the profession. This fact may be verified by reference to 
the works of the most distinguished writers of all schools, who 
say little or nothing on the subject; and also by a consultation 
with experienced physicians, who either know nothing of it, or 
who, taking an exceptional advantage thereof, have perhaps been 
enabled to make some remarkable cures. 

Now this case is atypical one. When you are consulted for 
the cure of a leucorrhceal discharge and find the patient with a 
rough, dry skin, a pasty, unhealthy look, an indolent habit of 
body, with swelling of the lymphatic ghrnds, deficient in stamina, 
impaired digestion, and a tendency in the leucorrhcea to alternate 
with some other affection, as a cough, a catarrhal disorder, or a 
diarrhoea, you may conclude that the strumous habit complicates 
the difficulty, and that your success in curing it will in a great 
measure depend upon your recognition of this fact. If to these more 
ordinary symptoms of scrofula it is added that the patient con- 
tinued to have the leucorrhcea throughout gestation, and that she 
habitually has a very copious flow of milk when suckling, as nearly 
all scrofulous women do, the modifying influence of this dyscrasia 
is the more pronounced and positive. 

Here then, is a constitutional cause which will serve to account 

for the intractable nature of the disease in a large proportion of 

cases, and for their failure to respond to the best 

Practical inferences. . ... . . ... 

chosen remedies, when those remedies are 
selected by the usual method. For there are not a few cases of 
this kind in which, in order to be successful, you must direct your 
attention to the underlying cryscrasia. You cannot cure this 
leucorrhcea by local applications. Merely to seal the flow by 
astringents, or by the use of any kind of caustic, would not touch 
the cause of the difficulty, and could not be thorough. The scrofu- 
lous habit, and the predisposition to glandular disease must be 
broken up by constitutional treatment before the local symptoms 
can be radically cured. 

Whether we are justified in promising entirely to rid our 
patients of a scrofulous, any more than of a rheumatic or a syphi- 



6^0 THE DISEASES OF WOMEN. 

litic cachexia, I very much doubt. And it follows that, if we 
cannot do so, we should be very careful about promising- to cure a 
chronic case of scrofulous leucorrhoea like this one. 

Treatment. — Women are generally better economists than men, 

but in the matter of wasting their own physical resources, they 

are sometimes very prodigal. Here we are in 

Economy of streng-th . " ° .... , 

the middle or winter. Ihis woman s child is 
more than a year old. Her health is wretched. She is a bank- 
rupt in strength and physical resource. But still she continues 
to drain away her little remaining vitality from a sense of duty 
to her child. The greater the lacteal secretion, the more 
copious the leucorrhoeal flow. She will never get well in this 
way. 

Ablactation, or weaning, is therefore the first remedy. The 

second is to put her upon a good diet. Milk, 
fo ^ d eaningandjrood cream, lean meat, eggs, and good bread and 

butter, are the best things for her to eat. Fresh 
air and the avoidance of fatigue are also indispensable. 

The third requisite is to find and supply such medicines as will 
counteract and overcome the influence of the scrofulous dyscrasia. 

Other remedies may be oriven incidentally and 

The remedies. . , 

upon the ordinary indications, for reflex and 
accidental complications, but the main dependence will be upon 
such medicines as calcarea carb., calcarea phos., mercurius, jod., 
arsenicum jod., silicea, natrum phos., ferrum phos., and jodium, 
or hepar sulphuris. This patient will take calcarea phos. 3, four 
times daily, and report. 

You will remember the case of M , a sewing-girl 23 years ol 

age who came to our clinic a martyr to a constant and copious 
uterine discharge. When she was not menstru- 

C(X86 

ating, she had the leucorrhoeal flow, and this 
double drain had induced the most unmistakable symptoms of 
chloro-anaBmia. She had palpitation, with cardiac irritability on 
exercise, and very decided symptoms of cerebral and spinal anaemia. 
Once she had a partial paralysis of sensation in the whole of the 
left half of the body, and which responded to the internal use of 
rhus tox. 3. 

For the leucorrhoea and the menorrhagia she was given calcarea 
carb. 3, with a steady improvement in all of her symptoms. The 



IRRITABLE UTERUS. 681 

monthly excess was the first to yield, and the anaemic symptoms 
soon disappeared. For the leucorrhcea she afterwards took sepia 
-3, with the affect to cure it. She was of a scrofulous diathesis, 
and this afforded an additional indication for the calcarea car- 
bonica. 

In this class of cases you will sometimes do well to prescribe 
the cod liver oil as a diet that is espec:ally adapted to the scrofu- 
lous constitution. It is an aliment merely, and not a medicine, 
and we may use it as we do the vegetable acids in stomatitis, or 
milk in Bright's disease, without any risk of interference with 
the action of appropriate internal remedies. 

IRRITABLE UTERUS. — HYSTERALGIA. 

Case. — Mrs. J , 27 years old, married, with three children 

the youngest of which is two years of age, has been an invalid for 
nine years. She is naturally delicate and sensitive. She was mar- 
ried at eighteen, and left home directly for a wedding trip, which 
was to consist of an excursion to a distant city and a visit of a 
fortnight to her husband's relatives. When she reached home 
she felt as if her nervous system was very much shattered. She 
attributes this result to a want of entire sympathy and accord with 
her husband, who she says, never understood her, and never took 
any especial pains to please or to gratify her. During her girlhood, 
alter fourteen, she suffered a great deal at her monthly periods, 
more especially for the first ten or twelve hours. For this she 
usually took hot teas, and gin, and kept to the bed. Since the 
birth of her children this dysmenorrhoea has not returned, but she 
lias not been well for a moment. Her chief complaints are of a 
fugitive character. She is wretched when she goes out, and when 
she comes in ; in the morning and at night. The only pains that 
she has are shooting, shifting and transient, mostly in the lower 
part of the back and of the abdomen. At intervals she has spells 
of lying in bed with these pains for several days. Sometimes 
there is strangury, particularly after coitus, which always worries 
and unnerves her. Menstruation is regular, but less free than it 
should be. She is most happy when in general society. When 
she can forgot herself, and be thoroughly diverted, she feels like 
another person. For this reason she likes to go away from home 
on a visit. Her nights are wakeful, and she dreams of every 
event, whether pleasant or painful, in her past life. Her feet are 
always cold. 

Examination does not reveal any sign of organic disease about 
or within the pelvis. The uterus is very irritable and tender to 
the touch. It seems to be slightly enlarged, but is not displaced. 
When the finger comes into contact with it she says it produces 



(>82 THE DISEASES OF WOMEN. 

the same painful tension and disagreeable feeling which she has: 
always experienced during intercourse, and which is so intolerable 
to her. 

There is a large class of diseases, of which this case is an exam- 
ple, in which the obvious organic lesion of the uterus and its 
appendages is the poorest possible criterion of the real nature of 
the complaint, of the suffering involved, and of the difficulty of 
curing it. The irritable uterus is not inflamed or ulcerated, con- 
gested or displaced. There is no lesion of 

Has no definite lesion. . 

structure connected with it necessarily. It 
yields no characteristic or critical discharge. Its measurements 
are normal, its regional anatomy is unchanged, and it offers no 
especial obstacle to menstruation, conception, or parturition. 

So far, therefore, as its morbid anatomy is concerned, it resem- 
bles nitrogen in being negative in its character ; for it consists 

essentially in an excitable or irritable condition 

A 'species of hyperesthesia. ,.,.,. , . 

of the womb, in which its nervous sympathies 
and relations are exaggerated and discordant. Inflammation of 
this or adjacent organs may exist as a sequel, or complication, but 
they are not a necessary part of the disease. So, also, in some 
cases there are incidental symptoms of spinal irritation, and of 
reflex disorders of every conceivable kind, which are contingent 
upon the morbid exaltation of uterine sensibility. 

This disease is limited for the most part to menstrual life. It 
occurs in the case of the married and the unmarried, but is more 

frequent among the former. Those who have 

Limited to menstrual life. 

been pregnant, whether they have gone to term 
or not, are believed to be more subject to it than such as have 
never conceived. There are, however, many exceptions to this 

rule. In general, those women who are weak, 

Predisposing causes. . 

nervous, and impressible, and who have been 
subject to slight, spasmodic and painful irregularities of menstrua- 
tion, are very prone to this disorder in after life. Unhappy mar- 
riage, the loss of property and of position in society, the lack 
of occupation, disappointment, solitude, the dread of having 
some "female weakness," inordinate use of tea and coffee, 
chagrin, jealousy, frequent abortion, too rapid child-bearing, 
erotic thoughts, and sexual excesses, belong also to this class. 



IRRITABLE UTERUS. 683 

of causes. The rheumatic and neuralgic diatheses are powerful 
predisponents of this form of hysteralgia. 

The exciting causes are also numerous. Whatever can directly 
or indirectly exalt the nervous susceptibilities and sympathies of 
the uterus (even if the stimulant he natural 
and harmless under different circumstances) 
is likely to work mischief if too frequently and carelessly applied. 
The emotions, which properly controlled are healthful and useful, 
may be in league with the passions to derange the uterine nervous 
system, and either or all of the functions connected therewith. 
Under their influence the womb may become so irritable that 
menstruation shall be suppressed, or become intermittent, scanty, 
profuse, or perhaps very painful, Or, through the uterine irrita- 
bility that is induced, a fruitful intercourse may be impossible, 
and sterility will be the result. 

Ungratified sexual desire is undoubtedly almost, if not quite, as 
injurious to the female in many instances as an excess of venery. 
For women are not only subject to sexual passions and propensi- 
ties similar to those of men ; but they are also under the dominion 
of a periodical crisis, that is attended by a peculiar exaltation and 
excitement of the generative system. These crises can not 
always be passed with impunity. They involve certain vicissi- 
tudes which derange the uterine innervation. And coming as 
they do so frequently, these nervous derangements are perpetu- 
ated. It is sometimes as difficult to tide a woman over "the 
month" as it is to carry a popular patient, who is very ill, over 
the Sabbath, or through a holiday, without a relapse, or an exac- 
erbation of his disease. The contingent excitement and re-action 
are so mischievous that it is almost impossible to counteract them. 
The result is an irritable condition of the uterus and of the whole 
sexual system. 

Other causes of this kind are the fitful, too frequent,and incom- 
plete performance of the sexual act, without regard to the menses,, 
or to the emotional state and desire of the female ; exercise, as in 
riding or walking while menstruating, or directly after the flow 
has ceased; getting up too soon after delivery, and especially 
after abortion ; too prolonged lactation ; frequent miscarriages ; 
the use of harsh or cold injections with a view to prevent concep- 
tion ; constipation, from paralysis of the rectum ; dancing, skating, 



684 THE DISEASES OF WOMEN. 

horseback riding, blows and falls upon the spine ; excessive Oi 
constrained muscular effort, as in running the sewing-machine, 
prolonged standing upon the feet, or sitting in a confined posture 
at a desk ; prolapsus, retroversion or retroflexion of the uterus ; 
pressure of the bladder, of the bowels, of the ovaries, or of some 
pelvic or abdominal tumor against the womb ; spasmodic and me- 
chanical obstructions of the cervix uteri ; ulceration of the vagina 
•or vulva ; nymphomania ; vaginismus, and ovarian irritation. The 
uterus is generally exempt from this form of irritation until after 
puberty. 

Some of the most intractable and painful cases of irritable 

uterus that I have ever treated have occurred in those women 

who, having been married for several years, 

From an early abortion. -i-ii t 

have had no children. In many of them con- 
ception took place almost immediately after marriage, but for 
reasons which seemed to them to be justifiable at the time, and 
without any adequate idea of the harm involved, measures were 
taken to force the flow, and, in short, to bring en an abortion. 
These measures were successful. The uterus was emptied of its 
contents. But the indirect consequences remained to torture 
them, and to impair their health and happiness for years to come. 
I could tell you the story of more than one beautiful woman who 
has suffered with this trying disease, whose health has been 
ruined, who has remained childless, and who would give the 
world if, when she was the bride of a few weeks, she had not 
swallowed somebody's "never-failing pills," or taken the wretched 
advice of a neighbor in this respect. 

Another fertile source of this uterine irritability is the reckless 
cauterization of the cervix of which I have already spoken so fre- 
quently. There are certain subjects upon 

From escharotics. -it • i • • n r> i 

whose delicate organisms this species oi retmed 
cruelty reacts with a most damaging effect. And it is a singular 
fact that those physicians who resort to it habitually become 
blinded to these results and indifferent of the consequences. Let 
me cite you a case to which I was called yesterday : 

• Case. — Mrs. , an intelligent, active woman of twenty-two, 

of nervous temperament, mother of one child two years old, has 
not been well for six months. Her household cares, and the worry 
with servants, the heat of the weather, and having to entertain an 



IRRITABLE UTERUS. 685 

avalanche of friends, had worn her down, and she was reduced in 
strength and spirits. She had no positive symptoms to complain 
of, excepting that she suffered from more frequent and severe at- 
tacks of sick headache (to which she was accustomed) than usual. 

For some weeks she tried to cure herself by means of domestic 
remedies from her own case, and finally by tonics of various kinds 
at the prescription of some of her friends. But her symptoms 
remained as before. She continued her household drudgery, did 
her own shopping and marketing, and, as usual, went to church 
and to Sabbath-school. 

Finally, through the advice of a neighbor, she consulted a lady 
ph}'sician, who cauterized the neck of the womb, and continued 
to do so twice each week, excepting the menstrual week, for six 
weeks. From the first application, she feh herself very much 
injured, and made worse ; but was advised to persevere, on the 
theory that, when she had once passed this purgatory, her feelings 
and experiences would be blissful enough. Each repetition of 
this cruelty unnerved her more and more. She could not sleep^ 
but walked the floor at night, lost her little remaining appetite, 
had cold, fainting spells, in which she would be unconscious for a 
long time ; she became discouraged and disheartened, melancholy, 
and, so her husband told me, practically insane for many hours 
after the caustic had been used. With this there developed a 
most tormenting strangury, and, after the second week, a corro- 
sive, itching leucorrhcea, although she had never had the slightest 
sign of either of these complaints before. 

At the end of the seventh week, after having had twelve of 
these " treatments," she deliberately came to the conclusion that 
her health would be utterly ruined should she persevere in this 
course. She therefore relinquished it, discharged her physician T 
and sent for me. 

Symptoms. — It would be quite impossible to give you all the 

symptoms of this curious disease in detail. In general the pain 

that is experienced is disproportionate to the 

Location of the pain. . 

uterine lesion. It vanes m its seat, and char- 
acter also. Usually it is located somewhere in the lower part of 
the back, or within or near the pelvis ; but very often it is situated 
in the head, the spine, the chest, or the abdomen. The pains are 
transient, paroxysmal and neuralgic, being for the most part, 
unaccompanied by any profound or peculiar constitutional dis- 
turbance. They are greatly influenced by emotional states, being 
either aggravated or relieved by certain conditions of the mind. 
Posture modifies the recurrence and severity of the paroxysms. 



686 THE DISEASES OF WOMEN. 

Most women who have an irritable uterus find it difficult to main- 
tain an upright position for any considerable 
Effect of posture and of length of time. They can not stand or sit more 

motion. o J 

than a few minutes without great suffering, and 
going up and down stairs is almost impossible for them. Often 
the reclining posture is the only one that can be tolerated. They 
may have a mortal dread of defecation and of urination, either of 
which is apt to be followed by extreme pain, exhaustion or faint- 
ness. Sometimes there is an irresistible desire to pass water, 
especially when she lies down ; again the urging to stool is equally 
tormenting whenever she sits up. And still the urine may be 
unchanged in quality, and the bowels remain costive. 

To these symptoms we must add those which simulate certain 
local disorders, as in the mimicry of Hysteria. The most common 
of these are dyspnoea, aphonia, palpitation of* 
€a ^ s ay sImulate other dis - the heart, angina pectoris, pleurisy, neuralgic 
pains in, and swelling of the breasts, especially 
before or during menstruation, ovarian aching and irritation, 
headache, facial and orbital neuralgia, gastrodynia, dyspepsia, 
chronic vomiting, depression of spirits, monomania, numbness of 
the extremities, muscular paralysis, and stiffness and uselessness 
of the joints. 

The nervous symptoms include insomnia, flatulent distention of 
the abdomen, dejection of spirits, emotional distress, great fluctu- 
ation of the feelings, sourness or suspiciousness 

Nervous symptoms. " . . 

oi temper, loss ox seli-control, lassitude, indif- 
ference, hypochondria, extreme sensitiveness to ridicule or to 
reproach, fickleness, jactitation, unrest, local or general spasms, 
tremors, partial paralysis, and circumscribed alterations in the 
temperature of the part affected. 

Of course these symptoms are not all present in every case of 
irritable uterus, but for every one of them that is lacking, you 

may find that ten or twenty others have been 
cio S u y s mptoms may be capri " acLclecl - I n brief, the symptoms are subject to 

the same variations, and are many of them as 
inexplicable as they are in hysteria, to which disease this affection 
is so closely allied. They are generally aggravated at the month, 
and are largely influenced by the state of the patient's emotions. 
She may be suffering severely, for example, with a pain which 



IRRITABLE UTERUS. 687 

alarms her family and makes her seriously ill. A friend calls to 
invite her to a drive, or a visit, and forthwith the symptoms van- 
ish. The family are horrified at her going out so soon ; and the 
doctor, who left her an hour before at home, may meet her miles 
away on a mission of mercy or of pleasure. 

Such a patient, who can not sit upright in her chair for five 

minutes consecutively, will sometimes get into her carriage, and 

r in a half-reclining posture, ride by the hour, or 

Contradictory nature of. . 

all the day long, without the least sign of 
fatigue or suffering. Or she will manage the affairs of her household, 
of the church, or of some charitable enterprise, with all the exec- 
utive ability of one who is well and able to withstand any amount 
of fatigue. And yet, in so far as the mastery of her own move- 
ments is concerned, she may be as helpless as an infant. 

An examination per vaginam, as in the case of Mrs. J., reveals 
a more or less sensitive condition of the womb. The cervix is 

tender to the touch, and if you push the organ 

Physical examination. -. , . . . . , 

toward the superior strait it pains the patient 
•exceedingly. In some cases the pain upon pressure is limited to. a 
small spot. The most delicate manipulation with a view to intro- 
duce the sound or the speculum occasions more of suffering than 
usual. Sometimes the uterus feels swollen and slightly enlarged. 
Occasionally it is more or less prolapsed, and in very rare instances 
it is either retroflexed or retroverted. 

Diagnosis. — This disease is sometimes confounded with coccy- 
odynia. But, in coccyodynia, whether from an injury sustained dur- 
ing labor, or from a fall or a blow, the patient 

From coccyodynia. . . . 

can not sit down squarely, or rise again without 
immediate and most excruciating pain, which is always referred 
to the point of the coccyx. In irritable uterus the pain is not 
always so limited, and she can usually sit from five to fifteen min- 
utes before the pain and the ill feeling come on. In the former 
the reclining posture is as painful as the upright one in sitting ; 
but not so in the latter. In the former there is likely to be a great 
increase of the neuralgic pain while at stool, and pressure with the 
finger in any direction induces a local paroxysm ; in the irritable 
uterus the suffering at stool is such as usually attends a consti- 
pated state of the bowels, and pressure upon the coccyx does not 
cause any very distinctive or extreme pain. 



68& THE DISEASES OF WOMEN. 

You would differentiate this affection from organic diseases of 
the womb by the absence of such discharges as are produced in 

uterine ulceration, and leucorrhcea. It need 
D F s r m?norfhSa disease ' _ not be confounded with dysmenorrhea, for in 

irritable uterus, although it is apt to be worse 
at the month, the pain recurs without any regard to menstruation,, 
and often continues from one month to another. 

Treatment. — Whatever predisposition the patient may have 
inherited or acquired should, if possible, be removed, in order 

that the proper remedies may work more effi- 

Remove the cause. . •tit 

ciently. bo also of the avoidable causes, pro- 
viding you can determine what they are, which in some cases is 
extremely difficult. To fulfil these indications may require much 
time and an infinite deal of tact, but, if you have the full confi- 
dence of your patient, and are sufficiently persevering, you will 
succeed in making life tolerable to her, if not in performing a rad- 
ical cure. 

In general you should remember that this class of patients are 
weak, debilitated, and badly nourished. If they take a sufficient 

quantity of food, it does not build them up as it 
stSngfh up the general should. Their vital force is low, and their strength 

is below par. They are too prone to depend for 
subsistence upon tea and toast, and crackers, and various little delica- 
cies which can not sustain them properly. They are very apt to 
loathe meat of all kinds, milk and all varieties of animal food r 
and from their habits in this regard to develop a species of neu- 
ralgic dyscrasia, which frequently underlies and may even cause 
the worst form of hysteralgia. 

The first thing to be done for such patients is to fortify their 
general strength and vigor by stimulating their digestion, and 

supplying them with the proper aliment. In- 
The mode and time of s t e ad of mincing their meals and eating under 

eating. <=> <=> 

protest in their rooms, apart from the family 
and alone, they should be brought to the table with others and 
tempted to eat more freely of good, substantial food. Let them 
" follow copy," as the printers say, and imitate those who have 
better appetites. 

The fresh air and sunlight are indispensable ; but the amount, 
and variety of exercise to be taken must depend upon the patient's 



IRRITABLE UTERUS. 689 

original strength, and the peculiar complications and history of the 
case. The more marked the hysterical tendency, 

Fresh air and exercise. 1 _ " ' 

the greater the need of will on her part, and 

determination to overcome the physical obstacles that lie in her 

path. Some of these patients need almost to be put out of doors 

before they will make the necessary effort to walk or ride, and 

thus learn for themselves that locomotion is among the possibilities. 

But it will not do to insist that all are alike in this respect. For, 

on the contrary, some of them will go too much and too far. They 

overdo in this direction, and need to be re- 

varying ability to take strained. And others are absolutely too weak 

exercise. J 

and too ill to take active exercise, regardless of 
its cost or consequences. The best rule with which I am acquaint- 
ed is to observe carefully how each one is influenced by the effort 
of going to ride or to walk, and thus to learn what she can bear 
and take within the limits of actual fatigue. She may be able to 
ride three squares not only with impunity, but with decided bene- 
fit, when to add one more square to the length of the drive would 
do her a positive injury. Long journeys are more tolerable for 
this class of our patients than they were before the days of the 
sleeping-car, but notwithstanding this improvement, many are yet 
injured by travel on the railways. When it is possible, and con- 
venient, it is best for them to journey by water. 

You will have so much trouble in regulating the habits of some 
of these patients in many particulars, that I am tempted to let you 

into a little secret which may help you to carry 

A practical hint. . J l J j 

your point, and to adapt your counsel to the 
end in view. First, make up your mind deliberately what prac- 
tice, or habit, or influence it is that lies in the way of their re- 
covery. Then set to work to reform or to remove that custom or 
influence, whatever it may be, by gaining the entire and willing 
assent of the patient herself. These indications cannot always, 
or perhaps frequently, be met in an off-hand or intuitive manner. 
They require the exercise of thought and of tact. And unless you 
can secure her confidence and co-operation, you certainly will not 
succeed. It may need a large measure of skill and of perseverance 
to bring it about, but you will learn that the art consists in hav- 
ing your own way, while she is under the impression that she has 
hers also. 



6*K) 



THE DISEASES OF WOMEN. 



A very common error in the treatment of the irritable uterus is 

to suppose that uterine surgery, as it is technically styled, and 

ordinarily practiced, will help to cure it. For 

Surgery contra-indicated. ^ *- 

the. truth is that, in this class of cases, it does 
more harm than good. There is not a single operation, or expe- 
dient of this kind, that is advisable in an uncomplicated case of 
hysteralgia. Caustics, the knife, the sponge-tent, the bistourie 
cachee, the sound, the probe, and pessaries of whatever variety, 
are so many instruments of torture. They invariably aggravate 
the disease. It is only when some of the incidental conditions 
that require such aid are superadded to the irritable condition of 
the uterus itself that the intelligent physician employs them in 
this disease at all. 

For the relief of the spinal, sacral and pelvic pains various 

topical applications are permissible and useful, the same as in 

other forms of neuralgia. Bathing the back 

Topical expedients. . 

with salt-water, dry frictions along the spine 
from above downwards, hot or cold water locally, the shower 
bath, pediluvia, wearing a thick layer of cotton batting along the 
back, the wearing of silk undervests and wrappers to insulate 
and protect the person against sudden electrical changes, paint- 
ing the painful part with the oleaginous collodion, dry cupping, 
porous plasters, arnica plasters, magnetism, electricity, galvanic 
belts and plates, and the use of bland and soothing injections per 
vaginam are the most common and useful of these expedients. 

I once called an old physician in counsel in a case of diphtheria. 
We had agreed upon the internal remedies, when my friend sug- 
gested that something, and the simpler the 

Why we should use them. 

better, should be prescribed lor external use, 
chiefly in order to keep the nurse and watchers busy with that 
which would do no positive harm, even if it did but very little 
good; for, said he, you know that "Satan finds some mischief 
still for idle hands to do." 

Acting upon this principle, and remembering the propensity 
of human nature to overdo in the matter of nursing especially, 
you had better advise some simple expedient that will "keep the 
nurse and watchers busy," rather than let them " fly to evils that 
they know not of." 

It is unnecessary to repeat what I have already said of the? 



IRRITABLE UTERUS. 691 

choice of remedies when speaking of the treatment of hysteria. 
There is no specific for the relief and cure of 

No specific treatment. . 

the irritable uterus. 11 the proper conditions 
are supplied and secured, medicines will achieve the most marked 
results. Otherwise they are powerless. The symptoms are so 
complicated, and oftentimes so contradictory, that you will find 
it very difficult to choose the most appropriate remedy. 

It is very probable that among the newer remedies, which of 
late have attracted so much attention, we may yet find a more 

ready means of cure for the various nervous 

The new remedies in. •<••-!■ 

disorders which are symptomatic of uterine dis- 
ease and irritation. For myself, I have come to place a deal of 
confidence in macrotin, gelseminum, caulophyllin, the lilium tigri- 
num, and senecin. Other members of this class are Scutellaria, 
ambra grisea, cypripedium and veratrum viride. But the old 
polychrests should not be forgotten. 

Mrs. J. will take a dose of macrotin three times daily, and have 
electricity applied along the spine twice per week — every Tues- 
day and Friday evening. I think it best in 

Prescription. i • • i i i ' i i • 

these cases that electricity should be used in 
the evening rather than in the morning or the early part of the 
day. She must also play the part of a good Christian philoso- 
pher, and not let her little domestic cares and trials fret and 
worry her too much. 



LECTURE XLII. 

UTERINE CANCER. 

Carcinoma uteri. General observations. Varieties. Causes. The subjective symptoms-.. 
The physical signs. Diagnosis. Course and duration. Case.— The cancerous Cachexia 
Prognosis. Treatment, local, medical and surgicl. 

General observations. — The term cancer is applied to malignant 
disease of the womb, and a peculiar interest attaches to its clinical 
history. Without entering into a discussion of the histology of 
carcinoma, it is enough to say that in all of its forms it is a fear- 
fully fatal disorder, and that its essential nature as well as its 
treatment are not fully understood. 

Varieties. — For practical purposes we recognize three forms of 
this disease: (1) the fibrous, or scirrhous, (2) the medullary, or the 
encephaloid, (3) the epithelial, or the cancroid form. The first, or 
the scirrhous variety is known among authors as the chronic form 
of the disease, and one in which the uterine tissue becomes hard, 
of a white or greyish white color, with such an absence of moist- 
ure as causes it to creak when it is cut with the scalpel. In the 
encephaloid cancer the surface is of a pinkish white, or rose color, 
with a caseous consistence, like that of the cerebral mass. The 
epithelial form is fungous or vegetating, with a tendency to 
ulceration. 

Most authors treat of two general varieties of uterine cancer, viz. 
that of the body of the organ, and that of the cervix, but they are 
essentially the same. 

Causes. — The most powerful predisposing cause is heredity. 
Age comes next, for it is most frequent at and after the meno- 
pause. Rapid child-bearing, and frequent abortions, especially if 
they have been induced artificially; chronic menstrual irregu- 
larities ; sexual excess, particularly in those who have borne chil- 
dren; and the immoral influence of city life belong to the same 
class of causes. It is very doubtful if any exciting cause could 
produce this disease independently of the cancerous dyscrasia. 

Symptoms. — There is no proper order for the advent of the 



UTERINE CANCER. 693 

symptoms; in fact they have usually existed for a considerable 
time before we are consulted. Perhaps the 
most constant of all the symptoms in every 
variety of this disease is the haemorrhage, and yet it is not present 
in every case. The form which it assumes, especially in the early 
stao-e of cancer, is that of menorrhaffia. But farther on the flow 
is more copious, or long-continued, and recurs without regard to 
the month. Generally, the nearer the approach to the climacteric 
the greater the amount of blood lost by this recurring haemorrhage, 
which, when the interval is prolonged, is sometimes mistaken for 
a continuance of menstruation. This haemorrhage in uterine cancer 
may anticipate the pain and the peculiar leucorrhceal discharges 
Avhich almost always accompany the disease. 

In advanced cases it is characteristic of this flow that it is caused 
or increased by the slightest movement; by mental excitement; 
by local irritation as from the contact of the finger, the use of a 
syringe, coitus, couching, or straining at stool; by the most care- 
ful introduction of the speculum or the sound, by lying upon one 
hip or the other, or by standing or stooping. The quality of the 
blood that is lost depends upon its excess and the duration of the 
disease. As the cancerous cachexia is more fully developed it 
becomes thin, mixed with a sanious pus and with the debris of the 
uterine tissue. 

The leucorrhceal discharge that accompanies the different forms 
of cancer, is sooner or later of a watery character, and peculiarly 
offensive. If the patient has been subject to leu- 
disc h h e ar^?° rrhCeal corrhcea, she is apt to make very little account of 
it, and you may be the first to suspect its connec- 
tion with a malignant disease. But you are not to suppose that 
because she has a fetid and watery discharge, therefore she must 
have uterine cancer ; for this quality of leucorrhoea may arise from 
the presence of a polypus or of a sub-mucous fibroid. In the 
early stage of epithelioma the odor is not offensive, but when it 
changes into the medullary form it becomes very much so. (Fig. 
114.) 

If a thin, acrid, and fetid leucorrhoea follows or alternates with 
an alarming haemorrhage, with a greenish yellow, a brownish, or 
a chocolate colored discharge, the chances are that the flow is of a 
cancerous origin. The odor of the flow which is characteristic, is 



694 



THE DISEASES OF WOMEN. 



sometimes so bad as to render the patient an object of pity,, 
and even of loathing to herself. Some authors have claimed 
that the contact of this ichorous discharge has not only caused a 
pronounced vaginitis, with more or less erosion, but also an 
increase of sexual desire. I believe this is a mistake. 

The quality and the degree of pain vary in different cases accord- 
ing to the seat and the extent of the lesion and the duration and the 
severity of the disease. Sometimes it is lacking 
altogether; again it does not appear until the 
affection is far advanced; and still again it may ccme at intervals 



The pain. 




Fig. 114. A sloughing epithelioma (Sims). 

and then disappear for a time. Its caprices in this regard, and 
the possibility that it may not be present are sources of deception, 
not only to the patient but also to the physician. As a rule the 
mucous forms of cancer are the least painful ; while those which 
involve the peritoneal coat of the womb are most so. 

The location of this pain is not always directly over the body of 
the organ, but on account of the infiltration of the cellular tissue 
in the broad ligament, it is very apt to be seated in one of the 
sides of the pelvis. If the infiltration has taken place around the 
cervix, as in pelvic peritonitis, the uterus will not only be anchored 
firmly, but the pain will be of such a character as to be aggravated 
by motion, the position of the body, and by the various causes 
already given. 



UTERINE CANCER. 695 

As the disease extends and encroaches upon other organs, the 
intra-pelvic pain and distress becomes more severe and constant; 
the lancinating pains give place to a dead, dull, heavy aching, 
with dragging sensations that torture the patient exceedingly. 
Horrible suffering is sometimes induced by the invasion of the 
bladder, and in other cases by its attacking the sacral nerves. 
Under these circumstances there is no rest and no comfort ; the 
patient cannot sleep, or eat, and is borne down in spirit by the 
knowledge and the thought that she will surely be a martyr to 
this disease. 

The reflex symptoms of uterine cancer are not distinctive; 

nevertheless the patient often complains of neuralgia, and ot 

radiating- pains in one or both of the mammary 

rii Hp rsflsx symptoms. 

glands, in the intercostal spaces, in the face, 
and in the upper extremities. 

The touch, either combined or singly, is of especial value in 
each of the varieties of cancer. The sensation imparted to the 

finger will vary with the location of the tumor, 

Physical signs of. . °. .... ., -, . . . , , 

its size, its texture, its age and period of develop- 
ment. Its sensibility, its immobility, the ease with which it is 
made to bleed, and the odor of the discharge upon the finger after 
direct palpation. In cancer of the womb especially, the touch 
will indicate the degree of phagedenic ulceration, the friability of 
the granulations, the extent to which the tissues have been 
destroyed, and the encroachment of the lesion upon the neighbor- 
ing structures. On account of the pain and the haemorrhage, that 
are induced by the most careful employment of the speculum, it 
sometimes happens that the physical examination of uterine 
cancer is limited to the touch. 

When it is practicable the speculum maybe used to confirm the 
signs that have been revealed by the finger. But it is only in the 
case of limited, or incipient cancerous ulceration, or of cancroid 
growths upon the cervix that we shall find what is distinctive in 
the field of the instrument. The irregular, fungous, or bleeding 
surface, which is of a greenish or brownish color, the tumefaction, 
and deformity of the cervix, and the quality of the discharge are 
included in these symptoms. 

In examining a case of this kind, it is of no use to employ a 
Ferguson's speculum ; and if you pass a duck-bill speculum, you 



696 THE DISEASES OF WOMEN. 

should be very careful in separating its blades not to induce an 
attack of metrorrhagia by wounding the ulcer- 

Jhe proper speculum ated gurface . ^ in ^ the diseage hag inyolved 

the vaginal walls, to create an opening into 
the bladder or the rectum. Sometimes a Sims' speculum, if care- 
fully applied, will do best ; but now and then you may expose the 
cervix most thoroughly and successfully by putting the patient 
in the Sims' position and separating the labia very widely with 
the fingers. 

I have known great harm to be done by the introduction of 
the sound in some of these cases. Besides the pain and the haemor- 
rhage that are likely to be induced, there is danger, when the 
tissues are devitalized, that it may pass into the peritoneal 
cavity. 

Diagnosis. — It is only in the first stage of the disease that the 

different varieties of uterine cancer are difficult of recognition. 

Fortunately it is most frequently located in the vaginal portion of 

the cervix, which is readily accessible to phys- 

In the early stage. . . . _ L 

icaJ exploration. 11 you are careful to remember 
and apply what I have said of the haemorrhage, the leucorrhceal 
flow, the character of the pain, and the constitutional symptoms, 
yon will not give a wrong diagnosis. 

In cervical hyperplasia, or corporeal cervicitis, the use of the 

sponge-tent, according to Speigelberg, dilates 
^From corporeal cervi- the part and c ii st i llg ui s hes the lesion from the 

fibrous, or scirrhous cancer of the cervix, upon 
which it would fail to make an impression. 

An intra-uterine fibroid might be attended with copious watery 
discharges that were offensive and bloody, but the sound and the 

conjoined manipulation would detect a tumor 

Prom uterine fibroids. . , T , , ~. . , , 

in utero. Moreover the larger size fibroids and 
polypi are almost never attached to the uterine cervix. 

The same rule applies to fibrous polypi, which as a class, have 
a disposition to appear at the internal os uteri, and then to recede; 

which are not sensitive when a needle is thrust 

From uterine polypi. . . . . 

into them ; which increase m size at the month, 
and which occasion expulsive pains like those of labor. There is 
however, a condition of degeneration of these fibrous growths 
which is styled sarcomatous, in which if the tumor sloughs away. 



UTERINE CANCER. 697 

or is removed, it grows again. These are the recurrent fibroids 
which are believed to be cancerous in their nature. So that, while 
in general we may say that a woman who has a uterine fibroid is 
in no danger of dying from cancer, we should be careful to 
qualify our diagnosis and prognosis in the case of these sarcoma- 
tous polypi. 

In very rare cases syphilitic ulceration may destroy the uterine 
cervix, and eat its way through the rectal or the vesical septum, 
as the cancerous ulcer is prone to do. But the 
uicer^ion PhllltlC varying constitutional symptoms, and the clini- 

cal history of the case will enable us to discrim- 
inate between them. 

Course and duration. — Although uterine cancer is a self-limited 
affection which, sooner or later, ends fatally, its course and duration 
are not constant. It may creep on insidiously, and continue for 
years without very serious impairment of the general health; or 
it may develop rapidly and run its course in a very few weeks or 
months. In all cases very much depends upon the period at which 
the ulcerative stage begins, the ability of the tissues to resist its 
inroads, the integrity of the general health and absorption of 
septic matters from the decomposing tissues and fluids. 

The rapidity of its course is shown in the following case, for the 
notes of which I am indebted to the husband of the patient, Dr. 
P. B. Hoyt, late of Paris, Illinois: 

Case. — I positively know that there was no local manifestation 

of the disease in the case ot Mrs. H , as late as the first of 

June, 1879. On the 20th of August, at her regular monthly 
period, she was taken with severe haemorrhage, which continued 
with more or less severity until about the 20th of November. The 
character ot the haemorrhage and of the other symptoms led us to 
believe, that she was passing through the climacteric period, and 
therefore created no apprehensions. 

The remedies, ipecac, hamamelis, and more particularly secale 
€ornutum and sabina, controlled the haemorrhage so well, that we 
w r ere certain she would come through all right, nor did the 
haemorrhage present any unusual appearance until about the 
middle of October, when she passed a number of very dark clots, 
attended with considerable pain in the back, and running down 
the left thigh. Sometimes these pains were very distressing but 
Pulsatilla, and gelsemium, relieved her. Some days she passed as 
many as from twenty to forty of these clots. There were strong 
contractions of the womb which caused the most excruciating 



698 THE DISEASES OF WOMEN. 

pains. On the 18th of Nov. she Avas suddenly taken with bearing 
down sensations attended with shooting, stitching, burning pains, 
which she compared to hot needles run up into the abdomen, 
causing her to bend forward, and support the abdomen with both 
hands. She laid down at once", and I gave her a dose of bella- 
donna 3. This entirely relieved the pain, Ave had visitors during 
the evening, and she Avas happy and cheerful as usual, she retired 
about 10.30 p. m., and slept quietly all night. 

The next day about 9.30 a. m., she Avas dusting the parlor, I 
was sitting in my office across the hall, and the doors were open, 
when suddenly I heard her cry out ; I sprang to my feet, ran into 
the room, and asked, " What is 1>he matter?" Her answer Avas 
" those same pains that I had yesterday, have come again, only 
ten times Avorse." I assisted her to the lounge, and at once gave 
belladonna as before, but this time it did not control the pains. 
It Avas several hours before she became even comparatively easy. 
Suspecting something serious I proposed an examination, but the 
opportunity did not offer until bed-time. On introducing the 
finger, I Avas never more surprised. The os-uteri Avas indurated, 
and enlarged, until it was at least tAvo and a half inches in diam- 
eter, and it and the Avhole cervix Avas covered with nodules, like 
little warts. 

After carefully noting her symptoms, I commenced treatment 
with calcarea carb. every tAvo hours, washing the parts Avith 
hot calendula water, and at night applied a cotton tampon, satu- 
rated Avith glycerine. My idea Avas, that if it Avas not purely of a 
cancerous character, the glycerine Avould reduce the induration,, 
but it tailed to accomplish this. I used at various times, as seemed 
best indicated, arsenicum alb., and arsenicum jodatus, silicea, and 
conium maculatum. I continued to apply glycerine medicated 
with the tincture of calendula, but to no purpose. 

Dec. 31st, 1879, we visited Cincinnati and consulted Drs. 
Hartshorn and Wilson. Dr. Hartshorn's diagnosis Avas " probably 
cancer." He recommended an application of chemically pure 
nitric acid, and to give internally, arsenicum jodatus, conium, 
thuja, or any remedy which seemed best indicated from time to 
time. 

The nitric acid treatment I did not approve of, because I felt 
sure that such strong applications would only aggravate the dif- 
ficulty. At Mrs. Hoyt's earnest request I did make one applica- 
cation, under protest, hoAvever, and the result confirmed my judg- 
ment and was not repeated. I iioav at the request of Dr. I. R. 
Haynes gave her juglans cinerea 6, internally, and applied 
glycerine medicated Avith the tincture of the juglans locally. This 
caused an increase of the profuse Avatery discharge from the vagina ^ 
After using it tAvo or three days I made an examination, and to> 
my delight found all the nodules gone. 



UTERINE CANCER. 699 

Two weeks previous to this we had visited Chicago, to consult 
Dr. Ludlam, who made a careful examination, and gave me his 
valuable advice for which I shall ever feel grateful, but his prog- 
nosis was decidedly unfavorable. When I found the nodules had 
disappeared, and Dr. Haynes having assured me that he had cured 
one case, and benefitted several others, I felt a little hope that his 
prognosis might prove untrue. But I soon found that the indura- 
tion had not subsided in the least, and that the ulcer was increas- 
ing in size and depth, and the parts were very tender to the touch* 
with a continual bearing-down pain. Indeed there was a decided 
prolapsus. 

At this time, the hips, back, thighs, and abdomen were very 
painful and tender, and the left thigh near the groin was much 
swollen. I now used the extract of hamamelis very freely, which 
mitigated the pain. A severe peritonitis now set in, whicu came 
near terminating her life, but by the local application of linseed- 
meal poultices, with the use of belladonna and aconite internally, 
we succeeded in reducing the inflammation, and she seemed better. 
There was, however, a great accumulation of fluid in the abdomen, 
which finally degenerated into pus, and was discharged per rectum 
the night before her death. 

After the peritonitis had subsided, we found the left ovary 
enlarged and very sensitive, and this condition continued until 
she died. Her strength now failed, and I could see that she was 
sinking rapidly. 

About five days before her death, she began to vomit, and no 
remedy was found to control it. The substance ejected was of a 
dark <4Teen color, almost black, and of an incliscribable odor. 
Towards the last, nothing was retained on the stomach for more 
than five or ten "dilutes, and finally after taking three or four 
spoonfuls of tea, she began to vomit worse than ever, and so 
rapidly that she could not raise it, and choked to death, at eight 
o'clock a. m., March 25, 1880. 

When the course of this disease is rapid it may carry the patient 
off before the symptoms that attend upon chronic cases have 

developed themselves. But when it has con- 
cachex C ia nCer0U8 tinued for months or years, and h is extended to 

the neighboring organs, with ulceration and 
sloughing, fetid and ichorous discharges, severe hagt.-iorrhage and 
intolerable suffering, the nutritive functions become impaired, 
there follows a species of slow poisoning, and the development of 
what is termed the cancerous cachexia. This cachexia is recognized 
\>y a peculiar earthy, or waxy, or tallow complexion of the skin, 
n ith a tendency to dropsical infiltration of the integument. 



700 THE DISEASES OF WOMEN. 

You must be careful however, not to confound it with copraemia, 
which is a form of blood poisoning that depends upon the reten- 
tion and absorption of faecal elements from the 
« Th ! «T^ mi t and intestine, and which produces a sallow, dirty, 

cancerous complexion. ' i ' J > 

hue, with unpleasant exhalations from the skin. 
I have known a prominent surgeon to pronounce a case as one of 
undoubted cancer, when the tumor and the peculiar complexion of 
the patient depended upon a lage accumulation of faecal matter. 
The case was afterwards cured by rectal injection thai softened 
the mass and brought it away. 

In some cases the final result is hastened by the occurrence of 
pregnancy, or rather by labor or abortion. If the induration of 
the cervical zone of the uterus is very marked 
nanc^anriaborupoT 11 ma y interfere with delivery, or resulting 
lacerations may cause a serio'is haemorrhage, 
or facilitate a fatal sepsis, It has even happened that, under these 
circumstances, the entire cervix has been torn oft* during labor. 

Prognosis. — The most that can be hoped for in any c se is that 
the course of the disease may be stayed and its inevitable result 
postponed. For, even where the lesion is most decidedly local, 
and we remove it, the disposition to a recurrence is a characteristic 
and constant symptom. So that, whether the constitution is 
primarily or secondarily implicated, the result is the same. Cases 
of spontaneous recovery that have been reported, are exceptions 
to the rule, and are not likely to be multiplied in your field of 
observation. Cases that have been reported as cured by this or 
that remedy are not authentic. 

It sometimes happens that a woman whose mother or sister may 

have died from cancer of the womb, or of the breast, has such a 

dread of this disease that we must not declare 

Carcinophobia. ... .. . , . 

our diagnosis too early, or too decidedly, bor a 
lack of cave in this regard may develop the form of mania that Dr. 
Thomas styles carcinophobia, or a dread of dying from this terrible 
disease. On the contrary, but under the s*»me circumstances with 
respect to heredity, a woman's mental and neivous condition 
may be such that she will not be satisfied unless you tell her she 
has cancer of the womb. It is not a fortnight since I was dis- 
charged from such a case because I could not find any trace of 
carcinoma, and had the conscience to say so. 



UTERINE CANCER. 701 

Many of you saw upon my table recently the case of a poor shop 

woman who had been under treatment for uterine cancer by a 

thief in the disguise of a doctor. Out of her 

Case. 

scanty earnings she had paid the scamp two dol- 
lars for each local application, which was repeated twice in each 
and every week, for more than a year. And yel, as you will 
witness, there was not a trace of cancer to be found anywheie. 

One mode of death from uterine carcinoma is shown in the case 

that I have just cited. Others die from fatty degeneration of the 

heart, from the supervention of cellulitis, septic 

Causes of death from. . „ . . , , , . J# , , , :, . 

infection, uraemia, phlebitis, and lymphangitis, 
with plegmatia alba dolens, and others still from inanition with 
marasmus. 

Treatment. — In the local treatment of this form of cancer you 
should not forget that the affected organ is strangely intolerant of 
irritants. Indeed, it is a serious nuestion whether the use of 
astringents, caustics, and stimulating washes, in cases where there 
was a suspicion ol malignant disease of the cervix, has not really 
developed it. I have no doubt that the use of these harsh means 
has often hastened, if not really induced these morbid growths, 
and it is not impossible that the radical change in uterine thera- 
peutics, which promises to put an end to the indiscriminate cauter- 
ization of the cervix, and to treat its diseases more rationally, will 
lessen the proportion of cases ol cancroid degeneration, and per- 
haps of other forms of uterine cancer. 

Whether Dr. Emmets' idea, that laceration of the cervix uteri, 

from being neglected is often the cause of epithelioma, and per- 

T .. „ +u haps of other varielies of cancer, is true or not, 

Laceration ot the ... . . . 

cervix, and uterine if this method of treating these lacerations is 
generally adopted, the uterus will soon be 
exempted from injuries that have been inflicted blindly, and with- 
out regard to their ultimate effects. If " prevention is better than 
cure," and his discovery really diminishes the proportion of cases 
of this terrible disease, Dr. Emmet will have builded better than 
he knew. 

The objects to be met by local treatment in 

Indications for local j j L ±. / 1 \ j. 

treatment. advanced cases of uterine cancer are, (1) to 

relieve the intra-pelvic pain, (2) to control 
the hemorrhage, and (3) to disinfect the discharges. 



702 THE DISEASES OF WOMEN. 

The best means of filling the two first of these indications is the 
resort to hot water vaginal injections. In very bad cases, how- 
ever, where the pain is chronic and insufferable, suppositories of 
opium or some other anodyne may be required. Iodoform mixed 
with almond oil, or with laid, one drachm to the ounce, may be 
applied by means ot a cotton tampon ; or a mixture of chloroform, 
glycerine, and sweet oil may be used in the same way. Occasion- 
ally we may take advantage of the anaesthetic properties of very 
cold applications, and Aran's expedient of passing a cylindrical 
speculum and filling it with broken ice may relieve the pain more 
promptly and decidedly than anything else. Local anaesthesia by 
the ether- spray, or the use of the styptic colloid with which mor- 
phia has been mixed, may do best. 

In some cases both the pain and the haemorrhage may be con- 
trolled by the local employment of hamamelis; and the styptic 
cotton is an expedient that is worth remembering in this connec- 
tion. Rest, during menstruation especially, and sexual abstinence 
will often prevent severe paroxysms of pain and of flooding ; and 
care as to the kind and degree of exercise that is taken will have 
the same effect. 

To overcome the fetor of the discharges, various means are in 
vogue, and you may need to try them all. Acetic acid, lemon 
juice, carbolic acid, pyroligneous acid, the chloride of lime, 
the sulphite of soda, thymol, bromine, iodoform, the perchloride 
of iron, the chlorinate of soda, or a weak solution of the iodide ot 
lead. Glycerine is an excellent anti-septic and will readily mix 
with most of these substances as a vehicle. It is very important 
to keep the parts clean, and for this purpose a little powdered 
alum, a few drops of creosote, or of a weak solution of the chlorate 
of potassa may be put into the water with which the vagina is 
syringed. This precaution not only keeps the parts clean, but it 
prevents infection from putrid absorption. 

I will not detain you with any extended remarks upon the 

medical treatment of this disease. For, although it is not unusual 

to find reports of cures that are claimed for iri- 

The medical treat- t x remedies t believe that such a result has 

meat. ' 

never really been accomplished. As you may 
suppose, the lesion being seated in an organ with a wide range of 
sympathies, and with functions that are peculiar, and the tendency 



UTERINE CANCER. 703 

of the disease being- always to involve other organs, and finally to 
implicate the whole economy, a great variety of indications may 
be presented, and a large number of remedies called for. When 
these indications present themselves you will affiliate the remedy, 
or remedies, to the case in point, as nearly as possible. 

There are a few remedies, however, which seem possessed of a 
clinical, if not of a curative relation to the cancerous diathesis. 
These are arsenicum jodatus, hydrastis can., conium, juglans cin., 
platina, phytolacca, kreosotum, and cod liver oil, it it can be called 
a remedy. Their use is very important, not only because they 
modify the dyscrasia, and thus prevent the more rapid develop- 
ment of the disease, but also because they may postpone its 
recurrence, when surgical means have been resorted to. 

As I shall tell you when I come to speak of epithelioma of the 
uterus (see Lecture XLIII), there seems good reason to place 
reliance upon the arsenicum jodatus especially. Here is a case in 
point: 

Case. — Mrs. W. , aged 45, a hospital patient, gave the 

following history; she is a widow, but has had no children, and 
no miscarriages. Her menses ceased five years ago. She inherits 
the cancerous diathesis, and is positive that a sister died of cancer 
of the womb. She dates her illness from an injury which occurred 
twenty-five years ago. While lifting a heavy weight she felt 
something give way within the lower abdomen. This sensation 
was accompanied by a report, or " snapping," and she insists that 
she has not felt comfortably for an hour since that time. 

She has had a more or less constant discharge from the uterus 
and the vagina, which is of a very offensive and corrosive character, 
and the internal genital organs are the seat of a burning pain, 
with extreme and almost insufferable tenderness to the touch. 
Since the menses ceased she has never had any haemorrhages. The 
abdomen is very sensitive, and after severe attacks of pain in the 
uterine region she sometimes passes a gill or more of pus, from 
the vagina. The stomach and abdomen are so tender and sore, 
that the weight of her own hand causes great pain when placed 
upon them. 

Sometimes these symptoms almost entirely disappear and the 
suffering is transferred to the mouth, the throat and the stomach. 
Again, she has a terrible burning, itching, and crawling sensation 
over the whole body, as if needles were sticking into every pore 
of the skin. Then red bunches, which vary from the size of a 
grain of wheat, to that of an e^g, and which also burn and itch 
severely are formed here and there. 

Before entering the hospital she had been under the treatment 



704 THE DISEASES OF WOMEN. 

of various physicians, chiefly for uterine catarrh and ulceration. 
She has worn pessaries and medicated cotton, and has been 
cauterized very severely for months together. She says that, on 
one occasion after the cotton had been applied as a means of in- 
troducing some very severe agent, its removal brought away the 
lining membrane of the vagina, and not in strips or shreds, but 
li the whole of it together." 

Local examination with the speculum revealed a high state of 
inflammation of the vaginal portion of the cervix. The posterior 
lip of the os uteri was the seat of a ragged looking and very vascu- 
lar ulceration, the anterior lip was knobby, swollen, and irregu- 
lar. By the touch the cervix was found to be fixed and immov- 
able, and very great distress followed the introduction of the 
finger into the Douglas pouch. The vagina was very narrow and 
exceedingly sensitive, although its w^alls were indurated, even 
down to the vulva. This condition had rendered it impossible to 
pass any but the smallest speculum. 

This woman remained in the hospital for three months under 
treatment, which consisted of the local use of the carbolized cosmo- 
tine (applied without the speculum) and internally, arsenicum, 
jodatus, in second decimal trituration, she also took lachesis 30, a 
few times. At the end ol that time her health was so much im- 
proved, that she went to the country where she remained for a 
year. Then she came back to the Hospital in much the same con- 
dition. But several months of careful treatment and-nursing was 
ineffectual in staying the progress of the disease. 

Feb. 10, 1881. Another year has passed, and her general health 
is improved, but locally the colpitis and the vaginal induration 
are no better. The cervix uteri which is nearly gone, is ulcer- 
ated, tunneled, and excavated, with hard margins and extreme 
tenderness, the old feted ichorous discharge has not lessened in 
quantity or improved in quality. 

She has found more benefit from the internal use of arsenicum 
jodatus 3, than any other remedy, and is satisfied that, without it, 
she must have died long ago. 

The question of surgical interference, whether by the excision 

of the diseased part, or the extirpation of the 

The surgieai treat- u t erus re vives the old idea that in some forms 

ment. ' 

of cancer, the disease is local before it becomes 
general, or constitutional. If the structural change is limited 
to the vaginal portion of the cervix, and to the lining membrane 
of the os and cervix uteri, and there are no evidences of a dys- 
crasia, it may be expedient either to amputate the cervix, or to 
remove the diseased mass by Sims' method, which I shall describe 
in my next lecture. 



UTERINE CANCER, 705 

The operation for the total extirpation of the uterus in malig- 
nant disease is a very serious one, and should 
Extirpation of the not be imc i orta ken in ordinary eases. Its risks 

uterus in. > J 

are fearful, and thus lar at least, the results 
scarcely warrant its performance. The difficulties in the way do 
not concern the operation itself, so much as the impossibility in a 
given case, of knowing* that the disease is primitive and purely 
local, and of deciding that it is limited to the uterus. For, it 
the constitution is involved and the cachexia is already established, 
or if the infiltration has invaded the broad ligaments, the pelvic 
cellular tissue, the peritoneum, the rectum, the bladder, or the 
glandular structures, its recurrence is inevitable. The whole 
issue hinges therefore, upon the strict localization of the lesion 
in the uterus. If you are satisfied upon this point, the way is 
clear for the resort to hysterotomy, or more properly, to hys- 
terectomy. You should be careful not to confound the question 
of ablating the uterus in carcinoma, with its removal in the case 
of an interstitial, or of a sub-peritoneal fibroid. 

" The first extirpation of the carcinomatous uterus was made by 
Andreas a Cruce, in 1650. In 1812, Gutberlet operated through 
die abdominal walls. Langenbeck and Delpech operated by this 
method, the latter successfully. Langenbeck and Sauter in 1822 
operated through the vagina. Sai iter's operation was successful. 
[n 1828 Blundell operated successfully per vaginani. Kecamier, in 
L82y, modified the operation per vaginam by ligature en masse of 
die lower part of the broad ligament by means of a curved needle. 
Delpech, in 1830, proposed a combination of the vaginal and 
abdominal extirpation. In 1876, Hering operated successfully 
without ligating the broad ligaments. Freund's operation, 1877, 
differs from all previous operations. He was the first to close the 
wound from the vagina into the abdominal cavity by sutures." 

Freund's method of hysterectomy is partly abdominal and partly 
vaginal. An incision is first made along the 

Freund's operation. ^ . . ° 

Imea alba, as in ovariotomy, but care is taken 
that its inferior extremity does not extend so far through the 
peritoneum as it does through the integument. The object of 
this precaution is to avoid the separation of the peritoneum from 
the anterior wall of the pelvis. The body of the uterus is then 
seized and held securely by the fenestrated ovariotomy forceps. 
The ovarian ligaments and the Fallopian tubes are next ligated, 
but in order that one thread shall be on each side of the uterine 



706 THE DISEASES OF WOMEN. 

artery, for its ligation when necessary, one end of each ligature 
is brought out through the abdominal wound and held, while the 
other end drops toward, and finally into the vagina. A trocar 
needle is then passed from the peritoneal cavity to the vagina and 
back again on each side of the broad ligament. This ligature, 
which does not include the Fallopian tubes, the ovarian liga^ 
ments, or the round ligaments, enters the vagina and emerges 
from it so as to include very little of its tissue; after which it is 
tied, and the ends are cut off. The next step, the bladder being 
protected by a sound, is to make a transverse incision through 
the part of the peritoneum which lies upon the anterior surface 
of the uterus, after which a similar incision is made through the 
retro-uterine peritoneum. Loops of silk are then passed through 
these peritoneal flaps, so that they can be held out of the way 
while this tissue is being dissected from the uterus. The con- 
nective tissue is separated from the cervix by the finger, or by 
the handle of the scalpel. Having reached the roof of the vagina, 
or nearly so, the utero-vaginal septum is divided by a curved bis- 
toury, and two fingers having been inserted in order to steady the 
organ, the uterus is finally separated and removed. The smaller 
arteries are secured by the ligature or by torsion-; all the loops 
and ligatures are brought down into the vagina; the abdominal 
incision is closed as in ovariotomy; and the vagina is filled with a 
large tampon or pledget of carbolized lint, which is kept in place 
by a proper bandage. 

This operation, which in the hands of its author gave a mortal- 
ity of 73 per cent., has been variously modified 
Bardenhauer's method, and improved upon. Bardenhauer combined the 
abdominal and the vaginal methods of extirpa- 
tion, by first detaching the cervix from below the vaginal roof; then 
opening the abdominal cavity and drawing the womb upwards; and 
afterwards, instead of ligating the broad ligaments en masse, tying 
each vessel separately, and finally by draining the peritoneal cavity 
through the vagina. This plan shortened the operation, made the 
haeniostasis more perfect, and by exposing the ureters to view, 
obviated the risk of their being ligated or otherwise injured. 

But in any manner, and by whomsoever it is made, the opera- 
tion of removing the entire uterus, including its supra- and infra- 
cervical portions, is a very severe and dangerous operation. It is 



UTERINE CANCER, 707 

l)ad enough to make a supra-vaginal hysterectomy and to ampu- 
tate the womb at or about the internal os-uteri, 
Caution. but you should not forget that even that operation 

is not to be compared with the complete extir- 
pation of the organ by way of an abdominal incision. These two 
terrible expedients are often confounded in the minds of physi- 
cians, and are spoken of so flippantly in our day, that those who 
are rash and inexperienced are sometimes tempted to undertake 
them. 

Of vaginal hysterectomy, and especially of Pean's mode of 
removing the uterus without the use of the liga- 
Vaginai hysterectomy in ture, I shall have something to say under the 
head of Uterine Fibroids. It must suffice to 
state in the present connection, that this form of uterine extirpa- 
tion, whenever it is practicable, is preferable to the supra-pubic 
method because of the readiness with which the separation of the 
organ is effected, the hemorrhage controlled, and abdominal drain- 
age secured. The risks are also lessened by avoiding a section of 
the abdominal wall and all injury to the peritoneum above the pel- 
vic brim. 

The consideration of Sims,' Schrceder's, Baker's, and other 
methods of surgical treatment for epithelial cancer of the uterine 
cervix, must also be deferred to another lecture. (See Lecture 
XLIII, page 717). 



LECTUEE XLIII. 

EPITHELIOMA OF THE UTERUS. 

Epithelial cancer of the womb. Two cases. Nature and clinical history of. Pathological 
anatomy of. Insidious course of. Symptoms. The cachexia. Diagnosis ; clinical 
observation versus the microscope in ; from cervical hypertrophy, and from uterine 
polypi and fibroids. ProQnosis. Effect of local irritants. Treatment, surgical and 
medical. 

Those, of you who were present at my sub-clinic, on Wednesday 
last will remember that, of the eight women who were placed 
upon the table for local examination and diagnosis, two of them 
had epithelial cancer ot the womb. I have thought to make those 
two cases the text for some remarks upon this form of uterine 
cancer. 

Case. — Mrs. T , aged fifty-one, ceased menstruating ^bout 

ten years ago, and four years ago her present illness began. 

She complains of intra-pelvic pain and distress, bearing-down 
sensations, increased desire to urinate, and prostration and debility, 
that are very much aggravated by exercise. She is subject to a 
leucorrhceal discharge, which is not very copious, neither is it 
offensive nor excoriating in character. Within a short time this 
discharge has become sanguineous, and the flow is perceptibly 
increased by straining at stool, by urination, and by ordinary 
exercise. 

Local examination showed that the cervix uteri was consider- 
ably tumefied but not discolored. The anterior lip was denuded 
of its epithelium and covered by a papillary growth, which was 
of a very dark red hue, and which bled upon the slightest touch. 

The outline of this formation was serrated and irregular. There 
was no evidence of scirrhous deposit in the surrounding portions 
ot the cervix. This patient was also the subject of a large umbilical 
hernia. 

The remedy prescribed was arsenicumjodatus, 3d dec. trituration, 
to be taken three times daily. An injection was also ordered, 
consisting of castile suds, glycerine and warm water. 

Case. — Mrs. , fifty-three years old, is the mother of eight 

children, the youngest of which is eleven years old. She says she 
has had a falling of the womb for twenty years. She complains 
of bearing down sensations within the pelvis, and pressure upon 

708 



EPITHELIOMA OF THE UTERUS. 



7oy 



the rectum whenever she is upon her feet, and whenever the 
bowels are moved. She has had a leucorrhceal discharge which is 
slightly offensive, and which consists of a bloody mucus; and 
which is increased by exercise. With the displacement, brought 
on by standing or at stool, there is a great deal of burning within 
the lower pelvis, which is sometimes almost intolerable. The 
menstrual flow ceased six years ago. 

Local examinations showed the uterus to be very much pro- 
lapsed ; the body of the organ was mobile, but the cervix was 
anchored in front, and considerably deformed posteriorly. It was 




Fig. 115. Cauliflower excrescence (ims). 

also nodulated, of a purplish hue, with a patch of epithelial 
ulceration of the same villous character as was observed in the 
former case. The ulceration was even more irritable and vascular 
than in Case 8,162, but the same treatment was prescribed. 

Nature and Clinical History. — These two cases illustrate a form 
of uterine cancer which is interesting, not only because of its 
comparative frequency, and its insidious character, but also because 
it is the only form of this terrible disease, if indeed there is one, 
that is curable. 

You remember the villous coat of the vaginal portion of the 



710 



THE DISEASES OF WOMEN. 



cervix uteri, and the beautiful arrangement by which each papillit- 
is covered with epithelium. It is these papillae, 
pathological anatomy and thig delicate i liyes ting membrane, which 

first become the seat of the morbid process in 
epithelioma of the neck of the womb. The former develop inor- 
dinately, and their loops of vessels and nerves supply the means 
for the exuberant hypertrophy of the mucous membrane which 
characterizes the disease, and which finally results in the ulceration 
and disintegration of the tissues involved. 




Fig. 116. Epithelioma of anterior lip ^ims). 

-This is the local beginning, the distinctive lesion of this variety 
of uterine cancer, which some very excellent authorities insist is 
always a local disease, the " cancroid" before there are any con- 
stitutional symptoms or complications whatever. 

Epithelioma, or papilloma of the uterus, is many times more 
common than the true cancer of the womb. It usually begins 
upon one or both lips of the cervix, in the form of a sort of 
tubercle, or prominence, which grows more or less gradually 
towards the os-uteri. This tubercle spreads, flattens out, is pretty 
hard to the feel, and bleeds very easily when touched. If it grows 



EPITHELIOMA OF THE UTERUS. 



711 



rapidly the papillae become swollen and enlarged, and take on the 
form of exuberant granulations that may fill the cervix like a 
cork, or find their way into the uterine cavity, or lie in, or crowd, 
the vagina in the form of what is commonly known asa " cauli- 
flower excrescence." 

The rapid proliferation of the cells covering the papillae, extends 
to the pavement epithelium on the free surface of the cervix and 
between these prolongations. When they have been so qi.ickly 
and imperfectly formed, the cells easily take on the morbid pro- 




FiG. 117 (Sims). 

cess, and inflammation or ulceration follow. So that if the growth 
is hastened, the local lesion becomes more serious and profound, 
and the general health begins to be impaired. 

You can readily understand why this affection may exist with- 
out the patient or any one concerned having thought of it. Its 
usual course is to creep along insidiously. 
Neither of the patients whose clinical history has 
just been read to you, have, as yet, any idea of the nature of their 
disease, which at their next visit, perhaps, must be explained. I 



Insidious course of. 



712 THE DISEASES OF WOMEN 7 . 

have said, in their hearing, that they have a form of carcinoma, 
and that satisfies them for the present. 

Symptoms. — During the early, or indolent period, there are few 

symptoms that direct attention to this disease, and, in fact we 

seldom see it until it has passed into the ulcera- 

The pain. . ,.,.,.. 

tive stage. 1 he pain complained ot is never acute, 
and is often lacking altogether. When it is present, it has a 
burning, stinging character, and is almost always worse alter 
exercise, coitus, coughing, sneezing, or straining at stool. If the 
cervix happens to lie forward against the neck of the bladder the 
chief distress is likely to follow urination. 

The vaginal discharge is not so constant nor so characteristic as 
in the other varieties of uterine cancer. In the early stage it is 

often absent, and it is not very rare to meet with 

The discharge. . 

cases, especially alter the climacteric, m which, 
although the disease may be far advanced, there is no increase in 
the amount of mucus that is secreted. But, when the vegetations 
are very luxuriant, and the case has taken on the form ot the 
cauliflower excrescence, or the " mushroom cancer," there will be 
a more copious and abundant flow of a watery mucus, or serum, 
that may deluge the patient, and cause the growth to shrink, to 
look very pale, and, perhaps, almost entirely to disappear for a 
time. 

The watery discharge usually, but not always, has an offensive 

odor, and is more or less corrosive in its character. At first it is 

not bloody, but, bv-and-by, as the ulceration 

The haemorrhage. , *1. ~ , . 

progresses, and the little loops ot vessels within 
the epithelial buds become involved, the flow is more sanguineous. 
Still, as a rule, these cases are not accompanied by such alarming 
haemorrhage as is common to the medullary cancer, and in rodent 
ulcer of the womb. The watery flow sometimes causes an intoler- 
able pruritis. 

Upon passing the speculum ver} 7 carefully (as you saw me apply 
it,) so as neither to cause pain, nor to bring on a haemorrhage, 

you will observe the growth. Its surface should 

Inspection of. . . ° .... , 

be mopped off m a very delicate manner and 
deliberately, and the patient instructed not to resist or to strain 
against the instrument while it is in situ, else the flow of blood 
will prevent you obtaining a correct view of the case. It may 



EPITHELIOMA OF THE UTERUS. 



713 



happen that the vagina itself is either so involved, or so filled with 
the growth, that it is not expedient to use the speculum, in which 
case we must rely upon the touch. 

Observe that, unless it is far advanced, this " villous cancer," 
as Rokitansky styles it, has not the form of an excavated ulcer, 
but of a growth that is super-imposed upon the cervix uteri. 
(Fig. 118). Its outline may vary, and there may be two or more 
distinct portions of it, but it's character is that of the cock's comb 




Fig. 118. Epithelioma oi both lips of the cervix (Sims). 

granulations which sometimes spring from the surface of ulcers, 
or of exuberant vegetations that may grow to 
ies1on? nSi ° n 0t thG almost any size. If the ulceration has progressed 
very far, the surface of the growth may be fur- 
rowed and bathed with pus. If caustics have been used, or a pes- 
sary worn, or the parts very much irritated from any cause, the 
lesion may have spread over the whole circumference of the cervix 
and to the roof of the vagina. (Fig. 114. ) In rare cases it extends 
to the meatus urinarius, where it causes great suffering from 
strangury. We had a very marked case of this kind (No. 1,763) 
in my clinic last winter. At other times, either through a con- 
tinuous extension of the lesion, or by inoculation from the leucor- 
rhceal discharge, it may reach the vulva. Instances have occurred 
in which the growth has begun upon the labia, and finally ex- 
tended to the uterine cervix. 



714 THE DISEASES OF WOMEN. 

Some months, or even years, may pass before the cancerous 
cachexia declares itself. The length of the interval varies with 

circumstances, as a rule, the disease develops 
cachJxi^ 1116111 ° f thG more rapidly at, or about the menopause, in 

consequence of rapid child bearing, or prolonged 
lactation, in women of a hemorrhagic diathesis, and of an im- 
poverished constitution, and especially in those whose domestic 
life has been unhappy or unfortunate. The delay in the develop- 
ment of the worst symptoms and results of this disease, in a con- 
siderable proportion of cases, has given rise to the belief that this 
form of cancer is sometimes radically cured. The average dura- 
tion of confirmed cancer of the womb is shorter than that of any 
other organ. 

The general symptoms, which indicate that the nutritive system,, 
especially, has become depraved, are a pallor of the face, the tallow 

complexion, with swelling and puffiness of the 
ment tritlVe deraD8:e " features and a lack ot expression, or a pinched,, 

anxious and care-worn look; weakness and! 
debility, loss ot appetite and disgust of food; emaciation and an 
aphthous tongue ; palpitation and cardiac disturbance upon slight 
emotion or exercise; alternations of constipation and diarrhoea; 
wakefulness and nervousness, with irritability ; paralysis, or coma, 
and even convulsions; increased fetidity of the discharges; dropsy 
of the extremities, with menorrhagia, and a kind of hectic fever, 
with signs of blood-poisoning, and a quick pulse, as in phthisis 
pulmonalis. Exceptionally these formidable symptoms run their 
course very rapidly, in which case, if the first stage of the disease 
has escaped detection, the poor patient may die almost before 
anybody realizes that she is, or has been in danger. But, usually, 
if she is not already very much enfeebled, their course is less 
rapid and alarming, and there is ample opportunity for confirming 
the diagnosis and for doing whatever we may for her comfort. 

Diagnosis. — Even when this stage of affairs is reached, it is not 
always an easy thing to differentiate this form of uterine cancer 

from affections with which it may be confounded. 

For this reason I urge you to study this subject 
very closely, and more especially also because in the whole range 
of medical experience, there is, perhaps, no disease in which the 
prognosis turns upon the diagnosis with greater precision and 
delicacy. 



EPITHELIOMA OF THE UTERUS. 715 

Do not forget, therefore, that, in this as in all forms of uterine 

and ovarian disease, where it is a question if tumors, or bits of 

tissue, discharges or ulcerations, are cancerous 

Clinical observation . ^ character, it is much safer to depend 

vs. the microscope. l 

upon what you will learn from careful clinical 
observations than upon what you can detect with your microscope. 
For, invaluable as that instrument is in the diagnosis of renal or 
other diseases, too much has certainly been claimed tor it in the 
detection of malignant disease of the womb. 

The educated " touch" is a better means of diagnosis, in epithe- 
lioma of the cervix especially. The peculiar feel of the growth, 
its form and friability, the ease with which one may rupture the 
thin covering of the blood-vessels, the swollen and sometimes 
nodulated condition of the neck of the womb, and the very ap- 
pearance of the finger when it is withdrawn, are of real diagnostic 
value. 

The flow may have an offensive odor in case of a partially de- 
tached or decomposing polypus or placenta, or from the decom- 
position of retained blood; or it may be very copious and watery 
where there is an infra-uterine fibroid, or from hydatids ; or it 
maybe heemorrhagic from chronic metritis, sub-involution, uterine 
polypi, membranous dysmenorrhcea, abortion, fibromata, or var- 
icose ulceration of the cervix; but the signs of the cancerous in- 
fection will be lacking in all these conditions. 

Reliable physical Thege iuc]ude the peci Vi iar fragility of the os and 

signs. l a j 

cervix uteri; the development of other tumors, 
either upon the neck of the womb or elsewhere ; and the anaemic 
and straw-colored hue of the skin. For, although one of them may 
be lacking, the others will not, in a case of genuine cancer of the 
cervix that has passed beyond the indolent stage. 

Epithelioma of the uterine cervix is a very rare affection before 
the thirtieth year ; and physicians of large experience have never 

seen ic in a woman who has not been pregnant. 

As in both of the cases under review, it is most 
common at and after the climacteric. 

You may know a case of simple inflammation and hypertrophy 
of the glands of the cervix, from one of epithelioma in its first 
stage, by the following symptoms: A cluster of glands, and not 
a single one only, are certain to be involved in glandular inflam- 



716 



THE DISEASES OF WOMEN. 



mation; the mucus is stringy, and has the properties of that 

which is secreted by these glands in health ; no 

Diagnosis from cer- matt how lai ™ tlae gj an d s have become, they 

vical hypertrophy. so- » J 

remain soft and do not bleed easily when they are 
touched ; and there is a line of demarcation between them and the 
cervix, that is lacking in epithelioma. 

The diagnosis ol cauliflower excrescence, within the cervix, from 
fibrous and mucous polypi of the uterus, is sometimes very difficult. 

Here again, we must rely chiefly upon the touch. 

If the growth that is felt is short and soft, and 
shaped like a raisin, it is a mucous polypus; but if it is long and 
narrow, it is probably a fibrous polypus. A polypus may retract, 



From uterine polypi. 




Fig. 119. Vaginal epithelioma (Sims). 

and bleed only when it lies within the cervix, which is not true of 
a papilloma. Besides, there is nothing about a polypus of any 
kind which gives the sensation as if it was brittle, and could be 
broken off, as tliere is in these malignant excrescences and papil- 
lary outgrowths. 

In epithelioma, the granulations are sessile, and, as I have 
already shown you, are found in patches of considerable size. The 
innocent growths that sometimes, although more rarely, follow 
a laceration of the cervix, are more fibrous and less vascular, and 
do not ultimately develop into a form of cancerous ulceration. 

As in examining for other varieties of cancer, you should not 



EPITHELIOMA OF THE UTERUS. 717 

forget the significance of the family history, nor of the co-existence 
of morbid growths in other localities. In a case 

The family history. c - . 

that was sent to me, during the last summer, 
from Ontario, the patient had had an epithelioma removed from 
the tongue a year before, and, some months before coming to 
Chicago, had found a suspicious tumor in her right breast. 

Where the local affection is far advanced, you will be very apt 
to find more or less swelling of the inguinal glands, and fixity, or 
anchorage of the cervix as a result ot the cancerous infiltration, 
just as in ordinary uterine carcinoma. 

Frognosis. — If this affection, whether it be local or general, or 
both, is really cancerous, the prognosis, in so far as the ultimate 
result is concerned, is, of necessity, fatal. Where cases seem to 
have been cured, the disease either returns or is translated to an- 
other tissue, or there has been an error in the diagnosis. 

Gruerin says*: " I have seen old women who have lived five or 
six years with an epithelioma of the cervix uteri. Those who live 
the longest are those who have escaped the application of topical 
irritants. 

In one of our cases (No. 8,164), the probabilities are that the 
development of the disease, from this date forward, will be very 
rapid: (1,) because a local examination shows that the cervix is im- 
movable, from the cancerous infiltration; (2,) because the neck of 
the womb is nodulated by reason of the deposition of the Fame 
morbid material into its substance; (3,) because the patch, which 
in this case is secondary, involves the pavement epithelium chiefly, 
and may therefore pass more readily into the ulcerative stage; and 
(4,) because, when once the process of destruction of the cervix 
begins, its course will, in all probability, be more speedy from the 
fact that it is already the seat of carcinomatous disease. The co- 
existence of these two structural forms of uterine cancer proves 
their real identity. 

Treatment — The surgical treatment of epithelioma of the uterus 

is in the best repute with those who hold most 

jhe surgical treat- strongly to the theory that in its early stage 

the disease is local, and may, therefore, be got- 
ten rid of by its destruction or removal. The first of these indi- 

*Lecons CI niques sur les Maladies ries Organes Genitaux Internes de la Femme. Par A.. 
Guerin. Paris: A. Delahaye, 1878, page 507. 



718 



THE DISEASES OF WOMEN. 



cations can be met by the use of such agents as the actual cautery, 
or the application of fuming nitric acid, or of chromic acid ; and 
the second by amputation, either with the electro-galvanic knife, 
the curette, or the ecraseur. 

The objections to the use of the electro-cautery in the removal 
of an epithelioma of the cervix uteri are that it is almost impos- 
sible to avoid injuring the vagina and the urethra, and that there 
is great risk of primary and secondary haemorrhage. Still the 
Paquelin cautery may sometimes be used with the Sims' spec- 
ulum. 

Dr. Sims' plan is to exsect the cervix piecemeal. His opera- 




Fig. 120. After the exsection. 

tion is not one of mere superficial amputation, but of complete 
extirpation of the diseased part. In a very 

Dr. Sims' operation. . . r . _ . 

interesting case, the detaus or which you will mid 
in the American Journal of Obstetrics, (Vol. XII, page 455.) the 
growth was attached to the anterior lip of the cervix. After its 
removal the neck of the womb presented the appearance shown 
in Fig. 120. 

Twelve months after the operation the patient returned to Dr. 
Sims with a recurrent epithelioma that was located on the pos- 
terior lip of the cervix. Fig. 121. 

Dr. Sims says : 



EPITHELIOMA OF THE UTERUS. 



71i) 



" The most unfavorable cases lor operation are those in which 
the epitheliomatous granulations penetrate deeply into the cavity 
of the uterus, and which can be readily removed with the curette. 
(Fig. 122) represents just what I mean. In such cases the mass of 
epithelioma projecting into the vagina is always easily broken 
down with the curette. There is but little work for the scissors, 
and more for the knife. The granulations in the body of the womb 
are removed in great masses with facility, and unfortunately, in 
all such cases, the haemorrhage will be profuse, and if the operator 
is not prepared to arrest it promptly it might become alarming 
and even dangerous. It is always of a bright arterial color, and 
seems to pour out from a thousand little arteries; for doubtless 
each filament of granular matter has its arteriole hypertrophied 
according to the nutriment necessary for fungoid growth." 




Fig. 121. Recurrent epithelioma of the cervix (Sims). 

Fig. 122 represents a rapidly fatal case of epithelioma of the 
cervix. 

I will quote the conclusions which are set forth by Dr. Sims in 
his excellent monograph : 

". . "Do not amputate or slice off an epithelioma of the cervix 
uteri on a level with the vagina, whether by the ecraseur or by 
the electro-cautery. 



720 



THE DISEASES OF WOMEN. 



2. Ex sect the whole of the diseased tissue, even up to the os 
internum if necessary. 

3. Arrest the bleeding, when necessary, with a tampon of 
styptic iron, or alum cotton-wool. 

4. Be careful not to apply the tampon with such force as to 
lacerate the excavated cervix uteri. 

5. When the styptic tampon is removed, cauterize the granu- 
lating cavity from which the disease was exsectecl, with chloride 
of zinc, bromine, sulphate of zinc, or some other manageable 
caustic, capable of producing a slough. 




Fig. 122. Epithelioma of the cervix and cavity of the uterus (Sims). 

6. After the removal of the caustic and the slough it produces, 
use carbolized warm- water vaginal douches daily till cicatrization 
is complete. 

7. After the cure, put the patient on the use of arsenic as a 
protection against the cancerous diathesis, and urge the importance 
of examination every two or three months for the purpose of 
detecting 1he recurrence of the disease. 

8. Then if fungous granulations or knobby protuberances not 
larger than a pea are found, lose no time in removing them; and 
treat the case afterwards with caustic just as in the first instance. 

9. Almost every case may be benefitted by operation, even 
when there is no hope of giving entire relief." 



EPITHELIOMA OF THE UTERUS. 



721 



Qalifying- indications. 



It is sometimes a very serious question to decide upon the pro- 
priety of resorting to these fearful expedients, more especially 
because the ' k localists," as they are called, are 
not always justified in asserting that, at any 
period whatever, the disease is wholly confined to the cervix uteri, 
without in the least involving the general constitution. And even 
if we were sure of it in the very incipiency of these growths, not 
one in a thousand of them is brought to our professional notice 
before the cancerous infection has taken place. It is not a parallel 




Fig. 123. An epithelioma in the field of the speculum (Sims). 

case with that of the " smoker's cancer," on the lip, where we can 
see, and watch, and then remove the suspicious-looking tubercle 
as soon as it begins to form, and can afterwards repeat the experi- 
ment as often as is necessary. 

You may depend upon it, that the surgical instinct is very apt 
to lead one astray, and under the circumstances in which these 
patients come to us, to tempt us to promise too much for them 
And moreover, when operations for the removal of this form of 
cancer are made, after the general system has become involved, 
they certainly tend to hasten the course of the disease. I have 
seen cases of this kind in which I would no more think of operat- 
ing with the electro-cautery, the knife, the curette or the ecraseur, 

46 



722 THE DISEASES OF WOMEN. 

than I would expect to cure a case of malignant diphtheria by 
stripping the membrane from the throat and fauces, or a case of 
anginose scarlatina by chopping oft* the tonsils. 

The local treatment that is permissible, at least in my own 

judgment and experience, is such as will tend to restrain the 

haemorrhage, if it is excessive, and to soothe and 

The local treatment. ° . . 

assuage the mtra-pelvic pain and distress. Hut 
we must be careful, at least in some cases, not to seal up the watery 
discharge too suddenly and entirely, else the suffering will be very 
much increased. The local use of hamamelis, hydrastis, calendula 
or thuja, with glycerine and water, often answers a very good pur- 
pose. All straining at stool, or in urination, should be carefully 
avoided and remedied. The bad odor of the discharges may be 
relieved by weak solutions of the chloride of lime, the perman- 
ganate of potash, or carbolic acid, or, in a domestic way, by 
pulverized charcoal, yeast, or lemon juice. To prevent re-infection, 
the parts should be kept clean, and the clothing also. 

Concerning the medical treatment, I am compelled to say that 
there is not upon record a single well authenticated cure of this 
disease by any remedy or remedies. A radical cure is not to be 
expected. And yet, if we begin in good season,- and continue 
perseveringly, and if the constitutional symptoms are not too grave, 
nor the course of the disease a very rapid one, very much may 
sometimes be done to retard its development and to delay its fatal 
progress. 

With this end in view, my own experience has led me to place 
my chief reliance upon two or three remedies, the first of which 
is the arsenicum jodatus. I usually prescribe it in the third deci- 
mal trituration, to be taken from one to four times during the day; 
and I really believe that through its employment some of my 
patients with epithelial cancer of the womb have been kept in a 
tolerably comfortable condition for months, and, in a tew cases, 
for years, before the inevitable result has finally overtaken them. 

The second ot these remedies is the mercurius corrosivus 6 which 
seems especially applicable to cases in which there is either a taint, 
or a strong suspicion of syphilis, and also where the lesion is 
located, as it is in very rare instances, about and within the orifice 
of the urethra. In the case to which I have already referred (No. 
1,763), the effect of this remedy was very marked and persistent. 






EPITHELIOMA OF THE UTERUS. 723 

You will find the history of this case in one of my clinics that was 
published in the United States Medical Investigator for December 
1, 1876. Three years and a half have now elapsed since this 
patient first came to us, but she is still active and comparatively 
well. 

Other remedies are mere, jodatus, nitric acid, natrummur., 
kreosotum, phosphorus and silicea. 

In one case which has been under our observation in the hospi- 
tal for three years, the chief complaint has been of the itching and 
burning ot the external genitals caused by the discharge that came 
from a cervical epithelioma. Under the internal use of arsenicum 
jodatus 3., and the local application of the carbolized cosmoline, 
which she applies once or twice daily, and sometimes oftener, that 
symptom has been kept under control. 

Before dismissing you I must remind you that the scraping of 

the part down to the healthy tissue by the dull 

The curette. curette, is a justifiable resource if the lesion has 

not extended too deeply toward the peritoneum, 

and if you use it carefully and in a good light, the parts being 

irrigated meanwhile with hot water. 

Still another expedient is what is known as Dr. Baker's oper- 
ation, which consists of applying the thermo- 
Dr. Baker's operation, cautery at a red heat. When this is thoroughly 
done the patient is put to bed and left undis- 
turbed. The hemorrhage will have been controlled, and there is 
no need of subsequent dressings. The slough is cast off in about 
a fortnight, leaving a granulating surface. The relief that is 
claimed may extend from a few weeks to several years. I shall 
speak of vaginal hysterectomy under the head of uterine fibroids 
and sarcomata. 



LECTURE XLIV 



OV4T11TIS. 

Ovaritis. Synonyms. Causes, medical, mechanical, epidemic, traumatic. Symptoms,, 
Prolapse of the ovary. leritoneal ovaritis. Dysmenorrhea and menorrhagia in. 
Case.— Gonorrhoeal do. 

Inflammation of the ovaries has been designated in medicine as 
ovaritis, oophoritis, oaritis, ovarite, and ovarian folliculitis. There 
are two excellent reasons why you should study the medical 
history of this affection most carefully. In the first place, the 
disease occurs more frequently than is generally supposed ; and 
in the second, our literature is lamentably deficient in respect to 
its pathology and treatment. 

Ovaritis may be acute or sub-acute. Some authors speak of a 
chronic variety, but this is included in the sub-acute, which is the 
more common form of the complaint. Indeed 
fre^lent ub " acute form most smce they differ only in severity and duration, 
one description must answer for all. Most 
authorities are agreed that the left ovary is more frequently 
inflamed than the right one. Out of forty cases collected by M. 
Chereau, the affection was double in four cases, seated in the right 
ovary in eleven, and in twenty-five cases in the left one. Tilt 
found the right ovary inflamed in but five out of seventeen cases. 
M. Tanchou suggests that the nearness of the left ovary to the 
rectum, and the mechanical pressure of fsecal matters upon it, 
may account for its greater liability to inflammation. 

Causes. — Ovaritis is rarely an idiopathic affection. It is liable 

to occur immediately before, during, or immediately subsequent 

to the appearance of the catamenia. In many 

Generally symptomatic. » _ . •, . 

cases, every return ot the menstrual period is 
characterized by marked symptoms of ovarian irritation and 
inflammation. The ovaries bear much the same relation to the 
uterus, that the Malpighian tufts do to the tubes of Ferrein and 
Bellini in the kidneys. Bearing in mind this intimate functional 
relation, you will readily perceive that amenorrhea, or retention 

7a t 



OVARITIS. 725 

of the menses, from occlusion of the vagina, by an imperforate 
hymen or os, or atresia of the vagina, or of the uterine cervix, 
would be likely to induce congestion of the ovaries, as well as of 
the uterus and Fallopian tubes. The repletion occasioned by the 
non-exit of the menses might be harmful in various ways, but the 
most painful symptoms incident thereto would be those of ovarian 
inflammation. 

A sudden suppression of the menstrual flow, as from cold, or 
coitus, has sometimes caused a severe attack of ovaritis. It may 
be due i;o spasmodic, obstructive or mechanical 
rw antls fr ° m dysmenor ~ dysmenorrhea, arising from partial obliteration 
of the uterine cervix. It is a frequent conse- 
quence and complication of membranous dysmenorrhcea ; and 
Drs. Rigby, Simpson, and others treat of a variety of painful 
menstruation under the title of Ovarian Dysmenorrhcea. If the 
monthly return is characterized by very considerable suffering, 
neuralgic headache, fugitive and erratic pains, and hysterical 
symptoms, one may suspect that the focal point of the disorder 
is in the ovary. 

There are perhaps few examples of menorrhagia of long stand- 
ing that are not dependent upon or associated with ovaritis. 

A frequent cause of the disease under consideration is the 

improper and harmful use of emmenagogues, which are given 

with a view to relieve menstrual suppression, 

From medical and me- or to i n d uce abortion. The resort to mecliani- 

chamcal causes. 

cal expedients for the same purpose may pro- 
duce a like result. These villainous appliances all act as irritants 
to the delicate structure of the ovary, tending to derange its 
innervation, circulation and nutrition, and thus, directly or 
indirectly, to induce the inflammatory process. Inordinate 
sexual indulgence, especially after prolonged or unusual abstin- 
ence, may cause ovaritis. I have met with several examples of 
this kind in women whose husbands had but just returned home 
after a long absence. Ungratified sexual desire, in those who 
are of amorous disposition, may likewise cause ovaritis. Some 
most painful attacks, due to this cause, are met with in young 
widoAvs. The same result has been witnessed in prostitutes 
when placed in confinement. The employment of unnatural 
means for the gratification of the sexual passions ; nymphomania ; 



726 THE DISEASES OF WOMEN. 

gonorrhoea ; or Menorrhagia in the female ; a too forcible coitus* 
as in rape ; falls or blows upon the iliac region ; the use of 
astringent vaginal injections, causing the sudden suppression of 
leucorrhceal, or a hsemorrhagic discharge ; the employment of 
eseharotics in ulceration of the os uteri ; the extension of endo- 
metritis through the oviduct to the ovary ; retroversion of the 
womb, and constipation, especially at the menstrual period ;. 
sudden exposure to cold, and check to perspiration ; emotional 
causes, as the reading of novels by those who are young and of 
sedentary habits ; unrequited affection ; the abuse of aphrodisiacs 
and alcoholic liquors, are among the more frequent and ordinary 
causes of ovaritis. Scanzoni reports having observed many cases, 
in which this disease was developed in consequence of an inflam- 
mation of a portion of the intestinal canal, and especially of the 
rectum. I have known it result from a sudden and intentional 
suppression of milk in a mother who had been suckling her 
child. 

The intimate relation existing between the functions of the: 

mammary glands and the ovaries is significant of ovarian lesions 

incident to the puerperal state. If the lacteal 

Epidemic ovaritis. . 

secretion does not appear at the proper time, 
the ovary is very liable to become irritated, and even inflamed. 
This inflammation extends by continuity of surface, to the peri- 
toneum. Hence arises a common sporadic and insidious form of 
puerperal peritonitis. . In 1746 an epidemic of this form of puer- 
peral fever prevailed at the Hotel Dieu, in Paris, and another in 
Vienna in 1819. Of fifty-six females who had died of puerperal 
fever, Dr. Robert Lee found that in thirty-two cases the ovaries, 
were red, swollen and softened ; and in two hundred and twenty- 
two cases of the same fever M. Tonelle found evidences of 
ovaritis in fifty-eight. Kiwisch remarked that, as contingent 
upon lying-in, ovaritis occurs generally in groups of cases, an 
observation that corresponds with the idea advanced by certain 
authorities, that it is sometimes epidemic. Kiwisch has often 
" made from ten to twenty consecutive autopsies without meeting 
with any considerable inflammation of the ovaries, after which 
the disease was observed, in more or less considerable develop- 
ment, in from six to ten individuals consecutively." 

Traumatio causes, incident to labor, sometimes give rise to- 



OVARITIS. 727 

ovaritis. Metritis may supervene upon delivery, and the inflam- 
mation extend through the generative intestine 

Traumatic ovaritis. . 

to the ovary, in some such manner as inflam- 
mation of the duodenum may indirectly extend to the liver. 

It is possible that, by reason of being compressed against the 
bony pelvis, the ovaries are sometimes injured during labor, but, 1 
as the gravid uterus occupies the superior strait, this result could 
happen only in exceptional cases. In the puerperal state, the 
absorption of post-organic matters from the cavity of the womb 
sometimes gives origin to a painful and dangerous form of this 
disease. Pus and other deleterious products may be conveyed 
by the oviduct from this cavity direct to the ovary, or lodged in 
the peritoneum, and thus serve to light up the inflammatory 
process. 

In rare cases, the rheumatic diathesis acts as a predisponent of 
ovaritis. This is an inveterate form of the complaint. In an 
example of the kind that I now have under treatment, the patient 
has, for six years, suffered almost martyrdom from rheumatism. 
For six months past she has had amenorrhcea, with prolapse of the 
left ovary, and ovaritis. A peculiarity worth mentioning is 
that an elder sister of hers died of rheumatism with menstrual 
suppression that had persisted for more than a twelvemonth. 

The " hysteric constitution," as it is styled by Roberton, is a 
marked predisponent of ovaritis. The class of patients most lia- 
ble to this inflammation are recognized as the nervous, irritable, 
and hysterical, those whose temperaments are mercurial and 
volatile. 

Symptoms. — In acute, post-partum ovaritis, the constitutional 
symptoms are marked and decided. As in inflammation of the 
serous tissues generally, the attack commences 
with a chill, followed by fever, acceleration of 
the pulse, and local pain. This pain is sometimes described as 
sharp and intense ; again it is forcing, throbbing, or dull, sicken- 
ing and paroxysmal. It may be seated in the upper and posterior 
portion of the vagina, in one or both of the iliac fossae, the groins, 
the lumbar region, the sacrum, the hips, or in the thighs, and occa- 
sionally reaches to the end of the toes. Sometimes, in lieu of a 
positive pain, there is a disagreeable feeling of weight and smart- 
ing in the region of the ovary, and patients not unfrequently com- 



728 THE DISEASES OF WOMEN. 

plain of a burning sensation in the same locality. On applying 
the hand to the hypogastric region, you may discover that there is 
really an increase of heat in the part affected. 

When decidedly paroxysmal, the sufferings may either remit or 

intermit. The iliac and hypogastric regions become exceedingly 

sensitive to the touch, so that pressure, palpa- 

Exercise — position. . . . 

tion and percussion are insupportable. I he 
least motion, more especially the attempt to sit upright in bed, 
increases the suffering, and syncope may result. In milder cases, 
riding and walking have a similar effect. One of my patients 
complains most of riding in a railway car. The thigh that cor- 
responds with the affected side is sometimes flexed, cannot be 
extended without causing much suffering, and on this account is 
rendered almost useless. She cannot sit, or stand erect, without 
extreme pain. When in the horizontal position, she prefers to 
keep the thigh flexed on the abdomen, and the leg on the thigh, 
in order to procure ease by relaxing the intra-pelvic and abdomi- 
nal muscles, and thus relieving pressure upon the tender and 
inflamed ovary. 

If the lesion involves any considerable portion of peritoneum, 

you may expect general abdominal tenderness, with tympanites, 

and other symptoms of true peritoneal inflam- 

Peritoneal ovaritis. . ..,,., 

mation. In post-partum ovaritis, whether it be 
a sequel to labor at full term or to abortion, the disease has its 
origin in this membrane (which is reflected over the ovary), 
whence it spreads rapidly, 

In consequence of its increased weight, produced by a species 
of strangulation and inflammation, the ovary is liable to a hernia 
or descent, posteriorly into the recto-vaginal space or cul-de-sac, 
laterally along the sides of the vagina, anteriorly between the 
uterus and the bladder, and even occasionally into the labia 
majora. In rare cases, this hernia of the ovary is congenital. 

The following interesting case of this kind is cited by Billard, 
(Traite des Maladies des Enfants nouveau-nes. Paris, 1833, p. 
474). 

" Josephine Romer, seventeen days old, was brought xo the 
Infirmary, September 12th. She was strong, and seemed pos- 
sessed of a good constitution ; the abdomen was somewhat tense ,* 
and at the left inguinal region there was a round tumor of the 



OVARITIS. 729 

size of a filbert, somewhat hard to the feel, which could not be 
returned to the abdomen, neither reduced in size by pressure, nor 
was its volume increased by the crying of the child. Its direction 
was obliquely towards the labium of the corresponding side, which 
it did not quite reach. On considering the location of the tumor, 
and although the sex of the child forbade the supposition, one 
could hardly resist the conviction that it was a congenital ingui- 
nal hernia. Our judgment was accordingly suspended until, at the 
end of twenty-six days, the death of the child from pneumonia 
allowed us, by dissection, to ascertain the nature of the tumor. 

* * * * The hernial tumor was formed by the left ovary, 
that had descended through the inguinal canal and ring, which 
were much larger than one usually finds them in girls. The 
uterus, drawn by the round ligament, and by the ovary that formed 
the hernia, had left its natural position, and was inclined to the 
left side of the bladder. The left kidnej^, instead of being on a 
level with the other, was drawn downward by an enveloping cel- 
lular tissue, and also by a fold of peritoneum, intimately con- 
nected with the orifice of the sac ; the renal artery and vein had 
also yielded to this traction, and both were elongated and nar- 
rowed ; and finally, the ovary and the fimbriated extremity of the 
Fallopian tube, somewhat reddened and swollen, were lodged at 
the base of the sac formed by the prolongation of peritoneum, 
with which cavity it communicated. There were no adhesions 
between the intestinal convolutions and the surrounding parts, 
and the opposite ovary was in its usual situation. 

" A careful examination of the round ligament on the side where 
the hernia was, satisfied me that it was much shorter than that of 
the opposite side, and that, in place of losing itself in loose fila- 
ments, it terminated in the labium by an aponeurotic expansion ; 
from which it would seem tnat the ligament, shorter, and more 
firmly fixed to the labium, had, in the first place, caused the 
uterine displacement, and subsequently drawn the ovary through 
the inguinal ring. It followed, from this abnormal adhesion, that 
all the movable, connected and contiguous parts on the left side of 
the abdomen were drawn to the side of the hernia, for they were 
not separated from each other, nor did they follow the abdomen 
in the intra-uterine development and enlargement of the foetus." 

The benign tumor formed by the displacement in ovaritis, 



730 THE DISEASES OF WOMEN. 

may vary in size . from that of a large almond, to that of a hen's; 
egg, or even larger. It is more swollen and sensitive at each men- 
strual period. This drawing, on the blackboard, will give you a 
pretty correct idea of the posterior and more frequent dislocation 
of the ovary, which you will remark has dropped into the recto- 
vaginal pouch, so that it is situated between the anterior wall of 
the rectum and the posterior wall of the vagina. 

The swollen ovary feels like an enlarged gland, is convex, and 
sometimes throbs and pulsates beneath the finger. The anal and 
vesical symptoms correspond with the variety and extent of the 
ovarian displacement. As a rule, the lower the organ, the greater 
the suffering. The tumor may press upon the broad ligaments 
and cause uterine deviations, or upon the veins and nerves within 
the pelvis, and occasion great suffering, paralysis, and, according 
to Cams, convulsions of the inferior extremities. 

But since, as Becquerel insists, these symptoms are common to- 
inflammation of all the organs contained within the lower pelvis,, 
how are we to decide, in a given case, if they depend upon ova- 
rian inflammation and consequent displacement ? In the more 
acute attacks of ovaritis, and particularly in lean persons, it is 
sometimes possible to detect the tumefied organ by examination 
through the abdominal parietes. In this case the swelling is cir- 
cumscribed and extremely painful to the touch. This is the most 
severe, or peritoneal form of the disease, which Scanzoni teaches. 
" is the only form accessible to palpation." 

In diagnosticating the sub-acute and chronic varieties, it is nec- 
essary to resort to the "touch." Upon making an examination 
per vaginam, we find the " tender spot" com- 

The vaginal " touch." . . . , 

plained of to correspond with the position of 
the prolapsed ovary. We may discover the tumor at the right or 
left sacro-iliac symphysis, or in one of the sacro-sciatic notches. 
If the displacement is a lateral one, we may confirm our suspicions 
by an examination of the corresponding groin, or iliac region, 
through the abdominal walls with one hand, while with the other 
we explore the vagina. 

It frequently happens that the patient winces or complains when 

the finger touches the uterine os or cervix — a 

Characteristic pains. 

circumstance that, unless one is very careful, 
may mislead in the diagnosis. Pressing the vaginal portion of the 



OVARITIS. 731 

cervix, backwards and laterally, occasions acute pain in the af- 
fected ovary. She declares that " she cannot bear to be touched 
just there," and may proceed to tell you that the same suffering is 
sometimes caused by contact of the male organ with that spot 
during coitus. One of my patients made a similar complaint in 
consequence of having touched the posterior vaginal wall at its 
superior portion, with the pipe of her syringe, which she had been 
told must be introduced high up into the vagina. 

The displaced and inflamed ovary is most easily felt upon exam- 
ination by the vagina when that canal is short, and the uterus and 
its appendages are not far removed from the 

The rectal " touch." . . 

vulva. But when the vagina is long, and the 
womb high up in the excavation, it is necessary also to 
resort to the expedient of exploration by the rectum. Plac- 
ing the patient in the obstetric position, with the thighs well 
flexed, the finger introduced into the rectum may be made to 
reach further, and acquaint us more fully with the degree of ova- 
rian swelling and displacement, than any other means at com- 
mand. This end is facilitated by the thinness and elasticity of 
the coats of the rectum, and the possibility of exploring the pos- 
terior surface of the womb, and even of the ovaries, in their nor- 
mal state. And this mode of examination may be rendered still 
more valuable in certain cases, by the employment of the free 
hand in abdominal manipulation — it being sometimes possible 
thus to press the tumor upon both its anterior and posterior sur- 
faces at the same moment. 

In the worst examples of prolapse of the ovary into the recto- 
vaginal space, the same end is gained by a resort to what has been 

styled the "double touch" of Recamier, which 

The " double touch." . . p . 

consists m the introduction 01 the index 
finger into the rectum, and of the thumb of the same hand into 
the vagina. By forcing the perineum upward, this expedient 
permits us to compress the morbid growth between the thumb 
and finger. The character of the resulting pain, and the shape r 
position and mobility of the tumor, are believed to be pathogno- 
monic of the disease in question. 

One of the most painful and persistent symptoms consequent 
"jpon a posterior prolapse of the inflamed ovary is an intolerable 



732 THE DISEASES OF WOMEN. 

sense of strangulation and obstruction of the bowel, following" 
the effort at stool. Rigby compares the charac- 
ter and quality of this suffering to that proper 
to orchitis, which, as you know, is almost insupportable. It is 
undoubtedly due to the pressure of foecal matter, and to the peri- 
staltic movements of the rectum upon the dislocated, swollen and 
excessively tender ovary. It may continue for hours after defe- 
cation has been accomplished. The symptoms induced thereby 
are sometimes mistaken for those of retroversion of the womb, and 
of stricture of the rectum. Constipation is an almost necessary 
consequence ; and it is possible, as has been claimed, that, in some 
cases, it may even tend to produce the displacement of the ovary. 
The whole alimentary system is liable to be deranged. The 
tongue becomes coated, the patient complains of thirst, anorexia, 
and, in rare cases, of obstinate heartburn, and even vomiting, as 
in the early months of pregnancy. The febrile symptoms corre- 
spond with the suddenness and severity of the attack. 

The vesical symptoms are sometimes so pronounced as to lead 

to suspicion of idiopathic disease of the bladder, and possibly of 

the kidneys also. When there is strangury, 

Vesical symptoms. . . .. i 

dysuria, heat and pressure m tile bladder, and 
these symptoms are greatly aggravated, or recur, only at the men- 
strual period, they signify that a sub-acute inflammation of one 01' 
both ovaries may be the cause of the suffering. You are not to 
conclude that they are necessarily the result of anteversion of the 
uterus, which affection, I repeat, exists more frequently in im- 
agination than in fact. 

The menstrual irregularities incident to ovaritis will not fail to 
attract your attention. The physiological theory that menstrua- 
tion consists essentially in the ripening and discharge of the unfe- 
cundated egg, or the " parturition of the ovum," as Tyler Smith 
most appropriately terms it, is now the generally received explana- 
tion of this process. 

The ovary is par excellence the organ of menstruation; the ma- 
turation and extrusion of the ovum, the first direct step in the 
process. This little organ, at once the most diminutive and im- 
portant of all the pelvic viscera, is a species of alarm clock, that 
introduces the element of time into the generative system, and 
presides over this function with respect to its occurrence and 



OVARITIS. 733 

regularity. Its organic symptoms are wonderful, and almost 
unlimited in their range and significance. Physicians are accus- 
tomed to speak of the " uterus and its appendages ;" a more cor- 
rect phraseology would be, " the ovaries and their appendages."' 

Retention of the menses is one of the most common and serious 

symptoms of sub-acute and chronic ovaritis. Young women are 

especially liable to that form of amenorrhcea, 

Menstrual disorders inci- described by the older writers as emansio men- 

dent to ovaritis. 

sium, a condition in which the menstrual flow 
has never been established. "When a simple suppression of this 
discharge- — suppressio mensium — occurs during the course of 
other diseases ; as, for example, in phthisis pulmonalis, and the 
protracted fevers, or from incidental causes, it may signify that one 
or both ovaries are inflamed. The cause has operated indirectly. 
The lesion is secondary or symptomatic. The effect is none the 
less palpable, and equally prejudicial to a complete recovery. 

It is impossible to treat properly such cases of menstrual irregu- 
larity without a knowledge of their special pathology. Some 
slight obstruction prevents the escape of the menses from the 
uterine cavity or the vagina. The new and abnormal pulse is 
reflected upon the ovary. Inflammation is the result, and the 
regularity and completeness of the function is disturbed for 
months, and possibly for years. Not to speak of the harmful con- 
sequences supposed to result from the non-elimination of certain 
matters contained in the menstrual blood, the suspicious charac- 
ter of the vicarious haemorrhages sometimes induced, or the lia- 
bility in many cases to the development of pectoral disorder from 
this cause, there is no question but that, in the great majority of 
instances, amenorrhcea is intimately connected with, and depend- 
ent upon, ovaritis. 

The varieties of dysmenorrhoea known as spasmodic, mechani- 
cal, and obstructive, implicate the ovaries in a similar manner, 
and are, therefore, to be regarded as incident 
ri Dysmenorrhoea and ova- to? anc i not dependent upon, the disease under 
consideration. The ovarian form of dysmenor- 
rhoea is always accompanied by ovaritis. The physiological injec- 
tion of the organ, so necessary to its functional activit} r , becomes 
excessive and exaggerated. The first stage of the inflammatory 
process is present, and the congested viscus is tender and painful. 



734 THE DISEASES OF WOMEN. 

All the suffering, which is paroxysmal, tormenting, and neuralgic 
in character, may be referred to the ovary. The lower part of the 
abdomen becomes extremely sensitive, and the patient undergoes 
a monthly martyrdom, accompanied by a distressing headache, 
neuralgia, and hysterical symptoms of every shade and variety. 

In my lecture on menorrhagia, you will recollect that I called 
your attention to the clinical fact that the most inveterate ex- 
amples of that affection had their origin in sub- 

Menorrhajia and ovaritis. . . . 

acute and chronic ovaritis. 1 o members of our 
school of medical faith, this fact is especially significant. The 
recognized superiority of our remedies for the arrest of profuse 
flooding can only be explained by their power to regulate, harmo- 
nize and restore the delicate vascular sympathies that exist be- 
tween the ovaries and the uterine mucous membrane. In illus- 
tration, I will read you the notes of a case upon which my advice 
was desired by Dr. B., a member of the class from Wisconsin. 

Case. — Mrs. , aged 18, married one year, came under my 

professional charge about three years ago. She is troubled with 
menorrhagia. The attacks have recurred at intervals for a period 
of two }^ears, for the relief of which she has taken domestic and 
allopathic medicines in large quantities. She was formerly strong 
and robust, but, on taking a sudden cold during the catamenial 
period, the menses were suppressed for nearly a year immediately 
preceding her last illness. The attacks of flowing last for a 
period of one or two weeks, and weaken her so much that she can 
scarcely raise her hand. The interval varies from three to four 
weeks, but is sometimes extended to eight or ten weeks. The flow 
is always long-continued, and profuse in amount. She had lost 
all reckoning as to the time for the recurrence of the regular flow. 

The discharge is sometimes dark and clotted, but more frequently 
of a thin, fluid character. Sometimes — and especially when the 
clots are passed — it is attended by much suffering, but, except- 
ing in the region of the ovaries, there is in general no pain. Both 
ovaries are tender and exceedingly painful, but only during the 
flow. 

She had been taking internally, and also by injections into the 
womb, most of the astringents laid down in the Materia Medica. 
In three months, by the use of pulsatilla, sulphur, nux vomica 
and sabina, giving the first two night and morning for a fortnight, 
and the last two for a like interval, and then repeating, I suc- 
ceeded in establishing the regular ''periods." Menstruation 
would then seem to be natural, the proper flow to continue for 
three or four days, after which, instead of decreasing, it would 



OVARITIS. 735 

increase, and consist of clots with arterial blood. The discharge 
would then continue for ten days or a fortnight, despite my best 
efforts to suppress it. For a time, drop doses of hamamelis 
seemed to check it, bnt after a little it lost its effect. 

This patient has never had any children, or, to her own knowl- 
edge, ever been pregnant. At times she has leucorrhcea, which is 
readily relieved by appropriate remedies. When I first saw her, 
the appetite was morbid, and she had lived upon rich and highly- 
seasoned food. She craved pickles especially. 

In this case, the nature of the exciting cause, the amenorrhoea, 
and the ovarian tenderness, assure us that the haemorrhage could 
not have been due either to prolapsus uteri, hydatids, or a cancer- 
ous affection of the womb. The doctor's success in establishing a 
periodical return of the menstrual flow is confirmatory of the view 
that its essential pathology was to be sought for in the ovaries. 
The throwing of astringent injections into the uterine cavity, by 
his predecessor, was a species of malpraxis which, besides being 
a positive injury, demonstrated the ignorance of the practitioner. 

Gonorrhceal ovaritis is, I am persuaded, more frequent than is 
generally supposed. According to M. de Meric ("London Lan- 
cet" for September, 1862), it is most liable to 

Gonorrhceal ovaritis. . 

occur during the acute stage of gonorrhoea m 
the female. In this it differs from the onset of orchitis in the male, 
which occurs towards the decline of the gonorrhceal discharge. 
This rule has many exceptions. The same author states that such 
an effusion and induration as takes place in the epididymis, when 
the testicle is inflamed, does not occur in the ovary in consequence 
of gonorrhceal ovaritis. Nevertheless, the character of the suffer- 
ing induced is very similar. However much the patient may com- 
plain of the vaginitis and urethral symptoms in case of gonorrhoea, 
the acuteness and severity of the pain in one or both ovaries, 
when they are the seat of this specific inflammation, is still more 
marked and decided. It closely resembles that of orchitis. 

As a concomitant of gonorrhoea in the female, ovaritis may 
undoubtedly result, as Dr. Tilt suggests, from " the immediate 
application to the ovaries of the blenorrhagic pus which has been 
convej'ed by the same capillary attraction by which the seminal 
fluid is conducted ; " from extension of the disease from the 
vagina ; or possibly from inoculation of the whole glandular sys- 
tem, including the ovaries themselves, with the specific poison. 



736 THE DISEASES OF WOMEN. 

The excessive tenderness of the vagina in cases of this kind, inter- 
poses a barrier to the employment of the "touch" in making a 
careful diagnosis, and hence this affection has been overlooked by 
a majority of writers and practitioners. I can not give you a 
better idea of this form of the disease than by quoting a case from 
M. de Meric's excellent paper. 

" On October 27, 1858, 1 was asked to see the wife of a wealthy 
tradesman in one of the metropolitan suburbs. She was said to 
be very ill, and I found her in bed. The patient was then about 
thirty-two years of age. She stated that, for three weeks at 
least, she had noticed an abundant discharge, which had consid- 
erably stained her linen with large yellow spots. The discharge 
had of late inci eased, and she had been obliged, on the day of my 
visit, to take to her bed, owing to a severe pain in the left iliac 
region. There had been a certain amount of uneasiness in mic- 
turition, but that had passed off. The last menstruation had 
occurred about three weeks before. 

" On examination, I found the patient suffering from feverish- 
ness; the linen shown to me was marked with large yellowish 
spots, and pain on pressure over the left ovary was very acute. 
The diagnosis of a case of this nature was seemingly easy enough. 
I suspected sub-acute metritis, the inflammation having suddenly 
extended along the Fallopian tube, and reached the ovary. This 
latter circumstance was explained by an imprudent exposure to 
cold, viz., driving home from the theatre in an open carriage. The 
pain was so acute that I did not propose a vaginal examination, 
but at once ordered fomentations to the left iliac region, a gentle 
purgative, an antimonial mixture, low diet, and rest. 

" It should be noticed that the lady was suckling a child about 
seven months olcl. 

" On leaving the house, the husband accompanied me, and 
inquired about the state of his wife, hoping it was nothing seri- 
ous. As he had been under my care, some years before, for gonor- 
rhoea, I thought it my duty to ask him whether anything of the 
kind had happened again ; and I learned that he had been suffer- 
ing from a slight discharge, which was going off. 

" The case now took a different aspect; and, after weighing all 
the circumstances, I came to the conclusion that my patient had 
been infected, and was laboring under gonorrhoea, the inflam- 



OVAEITIS. 737 

rnation having traveled to the ovary by way of the uterine 
cavity. 

u On the 29th, two days after my first visit, I saw the lady 
again, and found the discharge had diminished ; the pain over the 
left ovary Was still severe, though the pulse had somewhat come 
down. I proposed leeches, but so much repugnance was expressed 
that I advised counter irritation by mustard poultices, and the use 
of the same lowering means. The case progressed very favora- 
bly ; a few astringent injections were made as soon as the acute 
inflammation had gone by ; and in about three weeks the patient 
had so far recovered as to resume her household duties. I did not 
think it necessary to advise the weaning of the child. The father 
also regained his health in a short time." 

Some most painful attacks of gonorrhceal ovaritis arise from the 
use of strong astringent injections designed to stop the vaginal 
flow. I have recently treated a case of this kind, in which the 
husband ventured to prescribe the same injection for his wife that 
had been ordered for himself by a quack doctor. After a few 
hours she did penance for his infidelity and presumption, in a most 
severe attack of inflammation seated in both ovaries. Women 
sometimes resort to such harmful expedients at their own sugges- 
tion, and in a fit of desperation. I am greatly mistaken if in the 
future your professional experience does not prove that ovaritis 
is a frequent and most painful contingent of gonorrhoea in the 
female, Dr. Simpson and others to the contrary notwithstanding. 

At my next lecture I shall speak of the pathological anatomy, 
the differential diagnosis, prognosis, sequelae, and treatment, of 
ovaritis. 



LECTUEE XLV. 

OVARITIS — (CONTINUED) . 

Morbid anatomy of. Abscess in. Diagnosis. Prognosis. Case.— Sequelae. Menstrua 
disorders. Sterility. Treatment, do. of the puerperal form. Remedie in the cosm* 
mon form. Case.— Local remedies. 

In my last lecture your attention was directed to the nature, 
causes and symptoms of ovaritis. As related to the history and 
treatment of this disease, other points remain to be noticed. And, 
first, of its 

Pathological Anatomy. — You will not be surprised to learn that, 
until quite recently, the physiological anatomy of the ovaries was 
so little understood that distinguished physicians have been known 
to mistake healthy for morbid appearances, in these organs, at post 
mortem. It is related of the eminent anatomist Vesalius, that he 
referred the origin of symptoms of uterine strangulation, amenor- 
rhcea, and chlorosis, to the presence of yellow spots-, the modern 
corpora lutea, in the ovaries of four unmarried women, upon whose 
bodies he conducted an autopsy. 

The structural changes incident to ovaritis vary with the acute- 
ness of the attack, the brevity of its course, the seat of the lesion 
in one or another of the ovarian textures, its- 
relation to the last menstrual period, to labor, 
whether premature or at full term, and to the grand climacteric. 
As with inflammation seated in other organs, so in ovaritis, the 
more rapid the course of the disease, and suddenly fatal the attack, 
the more marked are the evidences at post mortem of congestion, 
and its immediate consequences. 

The line of demarcation that separates the physiological changes 
proper to the maturation of the ovum and the dehiscence of the 
follicle at each menstrual period — id est, the escape of a small 
amount of blood into the cavity of the Graafian vesicle, the retrac- 
tion of its walls, the formation of a clot, the fading hue of the 
coagulum, and the final cicatrix — from the more marked engorge- 
ment and effusion proper to acute attacks of ovaritis, is very indis- 



OVARITIS. 



739 



tinct and illy defined. In this connection, the following differential 
diagnosis between healthy and morbid ovisacs, as detailed by Dr. 
Farr, and re- arranged by Dr. Clay, in his notes to Kiwisch,* is of 
practical interest : 



NATURAL FOLLICLE. 

I. Always near the surface when prepar- 
ing for dehiscence, and often projects 
considerably above the level of the 
ovary. 



Coats unequally thick ; thinnest at the 
most prominent part of the follicle. 



3. Considerable vascularity above the 
elevated part, plainly visible exter- 
nally. 



Walls of follicle at this stage, of a 
bright yellow color. 



The liquor folliculi is either clear and 
limpid, or intermixed with blood, or 
the center of the sac is filled with a 
coagulum, which is at first bright red, 
and afterwards becomes pale, and at 
length nearly white. The coagulum 
may adhere to the walls, and undergo 
fibrillation and subsequent conversion 
into a solid body, or into a dense white 
membrane ; or it may be rapidly 
absorbed. 



MORBID FOLLICLE. 

Often not peripheral, but more or less 
central in its position in the ovary. It 
may attain to the size of one-third or 
half of the ovary, without necessarily 
causing any distinct prominence above 
the surface, especially when occurring 
singly. 

Walls are equally thick, and exhibit at 
no part any evidence of attenuation or 
absorption. 

No preparation for rupture is indicated 
externally, by any peculiar arrangement 
of vessels, or by any marked increase of 

vascularity. 

The walls do not exhibit the remarka- 
able yellow color, or the cerebral fold- 
ings, characteristic of the advancing 
normal ovisac, the tissues being com- 
posed of the undeveloped Graafian 
follicle. 

Contents of the sac are neither the 
clear liquor folliculi, nor the bright 
clot, nor the developed fibrin, but gen- 
erally a collection of dark coffee-ground 
matter, resulting from the admixture 
of a quantity of decomposing blood 
corpuscles, and fragments of membrana 
granulosa, intermixed with a dirty fluid. 



Any considerable engorgement of the ovary with blood, occa- 
sions an increase in the size and weight of the organ. The tum- 
efaction is accompanied by softening of tissue, 
^ The discoloration and the increased vascularity, and a change of color to 
a rusty dark red or blue, or even a mahogany 
hue. In idiopathic cases, which are rarely the subject of post 
mortem examination, an apoplectic effusion of blood into the fol- 
licles, and the subsequent formation of a coagulum therein, some- 
times results. As in cerebral apoplexj^, the size, complexion, and 
€haracter of this coagulum varies in different cases and in differ- 
ent stages of the disease. The masses are irregular or rounded, 



r isch on the .diseases cf the Ovaries, by Clay, London, i860, p. 63. 



740 THE DISEASES OF WOMEN. 

and sometimes as large as a cherry. The softer the c]ot, and the 
lighter its color, the more chronic or protracted has been the 
inflammatory process. Recent effusions" may supervene upon 
those of earlier date, in which case different follicles will be occu- 
pied with coagula of varying hues and consistency. Sometimes 
the wall of the follicle is hypertrophied, and rendered more firm 
than natural. In rare cases it is friable, and this species of hae- 
matic cyst may be ruptured, and its contents extravasated within 
the stroma, and the enveloping membrane (tunica albuginea) of 
the ovary, or into the peritoneal sac. Scanzoni details the case of 
" a young girl of eighteen years, who died suddenly during men- 
struation, with all the signs of an internal haemorrhage. The 
autopsy demonstrated in the right ovary, which was slightly 
amplified, a pocket of the size of a pullet's egg 

Haemorrhage into the ovary. ~,, , . -. . 

filled with coagulated blood, m the posterior 
wall of which was found an opening of nearly nine-tenths of an 
inch long, through which nearly seven pounds of blood had pene- 
trated into the abdominal cavity." In septic states of £he blood, 
as in the ovaritis of lying-in women, caused by the absorption of 
post-organic matters from the cavity of the uterus, the ovary may 
be engorged with effused blood from passive haemorrhage. These, 
and similar disclosures by the knife of the anatomist, have some- 
times caused the ovarian lesion to be entirely overlooked, and an 
off-hand, uninstructive diagnosis of pelvic haematocele to be made 
by the physician. 

Any of the various "terminations " of inflammation may some- 
times be recognized in the ovary. A very considerable effusion of 

serum into the peritoneal investment of the 

Dropsy as a sequel. . „ , n . -, . , 

ororan, or the collection of the same tluid m the 
distended vesicles, discloses a dropsical condition that may have 
escaped notice during the life of the patient. In the former case 
the tumor is unilocular, in the latter multilocular. It is more than 
probable that, as in pleurisy and pericarditis, this serum is at first 
exuded as a critical means of relief to the inflamed structure, and 
that subsequently the absorbents are not capable of removing it. 
When resolution has taken place, the structure of the ovary is 
changed. The retracted cicatrices make it more solid in consis- 
tence, with an irregular, bosselated surface. The glandular 
structure disappears, and may be substituted by various forms of 



OVARITIS. 71:1 

-heteroplastic growth ; as, for example, the cartilaginous, calcare- 
ous, cancerous, and possibly the tuberculous. Nearness to the 
grand climacteric increases the liability to atrophy of the whole 
organ. 

Puerperal ovaritis, whether peritoneal, parenchymatous, or fol- 
licular, and whether it occurs as a contingent of labor at full 
term, or in abortus, is most liable to terminate 

Liability to suppuration. . . . 

m suppuration. Abscesses of the ovaries are 
by no means uncommon. Their history is of the greatest clinical 
interest and importance. After death from puerperal fever, the 
puriform exudation may sometimes be found deposited in the folli- 
cle, which is thus enlarged to the size, perhaps, of a hazel nut. 
A description of these abscesses is thus given by Kiwisch (pp. 
cit. p. 90) : 

" Follicular abscesses, after a long continuance, may attain a 
very considerable size ; indeed, according to our own observations, 
they have contained about sixteen pounds of pure pus. The cyst 
w r all may resist perforation for some time, and, in isolated cases, 
for a long period of years. The parenchymatous abscesses are 
generally not so large, though we have seen them reach the size 
of a child's head ; and we have also to observe that they com- 
monly increase much quicker than those previously mentioned. 
These abscesses often proceed from several small foci, which coal- 
esce in the course of time, and the greater part of the stroma of 
the ovary is destroyed, or a sinuous cavity is inclosed in its rudi- 
ments. After a protracted duration of the disease, these collec- 
tions of pus are surrounded by a membrane ; but it is difficult to 
separate from adherent parts, and it cannot be anatomically 
demonstrated to any extent. The disposition to perforation is 
a characteristic feature of these abscesses ; in the acute form of 
the disease, it may take place in the course of a few days or weeks. 
The cystless abscesses in the neighborhood of the ovaries, are 
also disposed to perforation. Consecutive collections of pus, in 
previously degenerated follicles, seldom burst, with the exception 
of those cases in which the contents have an ichorous property." 
The pus contained in the ovarian abscess, in most cases, is laud- 
able ; but, occasionally , ichorous and corrosive. 
The danger of rupture and extravasation of 
the contents of these abscesses, is proportionate to the bad 



742 THE DISEASES OF WOMEN. 

quality of this purulent matter, complicated perforations being 
more frequent where the pus is of an ichorous and disorganizing 
character. 

The abscess may discharge its contents directly into the abdo- 
men, with fatal consequences. A case of this kind is cited by Dr. 
Seymour, from Guy's Hospital Reports.* 

" The patient was a young woman, of the lowest and most un- 
fortunate class of females. She was greatly emaciated, had a 
very quick and feeble pulse, a shining red tongue, and constant 
watchfulness. She suffered from constant and irrepressible diar- 
rhoea, and for many successive days vomited both food and medi-' 
cine , the catamenia were absent. * * * * After having 
been in the hospital about two months, she suddenly complained 
of the most acute pain over the abdomen, and, in a few hours,, 
expired. 

" On opening the abdomen, death appeared to have been pro- 
duced by the effusion of a large quantity of pus into the peritoneal 
cavity, which escaped from an abscess in the right ovarium, which 
abscess appeared to arise from suppuration in the substance of the 
viscus, similar in every respect to phlegmonous abscess in any part 
of the body, and not connected with any cyst, or change, or addi- 
tion of structure, the product of morbid growth." 

Collections of benign pus in the ovaries may find an outlet 
through the bowels, the bladder, the uterus, the vagina, or the 
abdominal parietes. They seldom perforate the 
Extemporized outlets for sma u intestine, but more frequently communi- 
cate with the rectum, on the left side, and the 
colon on the right. Serious consequences, from the escape of the 
purulent collection, are prevented, by the formation of adhesions 
between the neighboring structures. Many obscure cases of renal, 
uterine, and rectal disease originate and culminate in this effort of 
nature to extemporize an outlet for the contents of an ovarian 
abscess. Fistulous abscesses of this sort are sometimes salutary, 
and again intractable, chronic, and necessarily fatal. In rare 
cases they may discharge, repeatedly, through the unnatural out- 
let. It should not be forgotten that, although it may take place 
in the unimpregnated female, ovarian suppuration occurs most 
frequently, in consequence of post-partum injury or inflammation^ 

* Seymour on Diseases of the Ovaria ; p. 38. 



OVARITIS. 743 

The quantity of pus contained in the ovarian abscess may vary 
greatly. In most cases it is not very large. Examples are, how- 
ever, recorded, in which an incredible amount 
P u? formeT quantity ° f lias been observed. Dr. Taylor, of Philadel- 
phia, reports a case of chronic ovaritis affecting 
the right ovary, in which the sac weighed seventeen pounds, and 
yielded sixteen quarts of pus. It sometimes happens that the 
purulent matter, with which the stroma of the ovary and the 
tissues of adjacent organs are infiltrated, is itself decomposed. 
In this case the evidences of fatal peritonitis are superadded to 
lesions already noted. Kiwisch says (pp. tit. p. 92) : 

" The more acute the progress of an ovarian abscess, the 
slighter is the thickening of its walls, and the more benign its 
pus ; but much more frequently it happens that, after its contents 
have been evacuated externally, complete contraction and 
obliteration of the pus cavity takes place. This is observed 
particularly after parenchymatous inflammations, and the intra- 
peritoneal suppurations surrounding the ovaries. Those absces- 
ses, however, whose walls are highly organized, which are not 
excavated for months or years, particularly when the point of 
rupture has no favorable direction, generally cause exhaustion, 
in consequence of the frequent renewal of the decomposing pus, 
or become fatal by the supervention of pyaemia." 

The post mortem disclosures in ovaritis, chiefly affecting the 
peritoneal investment of the ovary, are of the kind proper to 
serous tissues generally. Sometimes the most extensive adhesions 
are formed. " Thus the ovary may become agglutinated to the 
broad ligaments, to the pelvic parietes, the uterus, the bladder, or 
the rectum and the sigmoid flexure, to the caecum, the vermiform 
process, and the small intestine ; and it is generally attached to 
several of those viscera at the same time.*' The fibrous bands 
that connect these various organs and surfaces, belong to the 
variety of pseudo-membrane, classed by Laboulbene as " perman- 
ent," which are themselves subject to diseased conditions. In 
some cases a considerable increase in the size and weight of the 
ovary may be due to an excessive development of the fibrinous 
exudation. 

The various lesions we have detailed are seldom found uncom- 
plicated with, those of inflammation of adjacent organs and 



744 THE DISEASES OF WOMEN. 

structures. This is especially true of puerperal ovaritis, which, 
as we have said, is apt to run its course with metritis, endo- 
metritis, or peritonitis. 

Beraud, Trousseau and others, treat of a form of ovaritis which 
is contingent upon variola, (l'ovarite vario- 

Variolous ovaritis, . 

leuse). It may attack either the parenchy- 
matous structure or the peritoneal envelop of these organs. 

Diagnosis — The diagnosis of ovarian affections is, sometimes, 
very difficult. This is especially true of the sub-acute and 

chronic varieties, unconnected with the puer- 

Characteristic symptoms. 

peral state. When the patient is extremely 
sensitive, and especially where it becomes necessary to explore 
the rectum, we may resort to the employment of anaesthetics with 
advantage. I have already given you a full description of the 
symptoms of ovaritis. The character of the suffering, its periodi- 
cal aggravation with each return of the catamenia, the menstrual 
derangements incident thereto, the symptoms of strangulation 
and inflammation from a hernial descent, or other displacement 
of the floating organ, the circumscribed swelling, the constitu- 
tional effects, and the sequelae, are sufficient to enable you to 
distinguish this from other diseases of the female generative 
system. In making out the differential diagno- 
The principle of ^ exciu- s j s f ovaritis, in its various forms, it is well to 

sion. ' 7 

proceed upon the clinical principle of exclusion. 
Having examined if there be any disease of either of the neigh- 
boring organs, and not finding it present in a given case, we are 
confirmed in our diagnosis that the affection is ovarian. As 
explained in my last lecture, the ''touch" is an invaluable aid in 
all doubtful cases. 

Prognosis. — In the milder forms of ovaritis uncomplicated with 
organic disease of other portions of the generative apparatus, the 
prognosis is favorable. Very considerable structural changes 
may be resolved away, and the general health and vigor rein- 
stated. The most obstinate examples of this disease are com- 
plicated with menstrual disorders, more particularly with menor- 
rhagia. In the gonorrhceal type, when it does not result in 
suppuration, the symptoms are likely to become intractable and 
obscure, although most cases recover sooner or later. When 
there is ulceration of the womb, and the patient has been under 



OVARITIS. 745 

treatment therefor, especially if the os and cervix have been 
frequently and severely cauterized, the prognosis should be 
guarded. 

When acute ovaritis supervenes upon abortion, the danger is in 
ratio with the advanced state of pregnancy at which the miscar- 
riage has taken place. The more advanced the 
The danger from ovaritis period of gestation, the greater the danger. 

after abortion. i o ' O O 

Much depends also upon the cause or causes 
that have produced the abortion. As the normal stimulus for 
uterine muscular contraction is derived from the ovaries, so it is 
reasonable to suppose that any agency that produces a like result, 
whether medicinal or mechanical, vital or villainous, must oper- 
ate through the same medium, and thus implicate these organs 
more or less seriously. The prognosis will vary accordingly. 

As a contingent of child-bed, the danger varies with the history 
of the previous labor, the patient's vigor of constitution, the cir- 
cumstances by which she is surrounded, the 
_^As a contingent of lying- care & \ ie receives, and the epidemic prevalence of 
puerperal peritonitis. The occurrence of rigors 
that alternate with fever of an irregular type, local ovarian pain 
and anguish, a frequent pulse, colliquative sweats or diarrhoea, 
suppression of the milk or lochia, with tympanites, dyspnoea, 
great prostration, and copious deposits in the urine, are untoward 
symptoms. Rupture of the haematic cysts, and of the ovarian 
abscesses, and the extravasation of their contents, ma}^ prove sud- 
denly fatal. Under these circumstances, the patient sometimes 
dies as abruptly and unexpectedly as if from perforation of the 
intestine in typhoid fever, or from the bursting of an aneurismal sac. 
Ovarian suppuration is not necessarily fatal. We should, how- 
ever, qualify our prognosis most carefully. Where the accumula- 
tion of pus takes place rapidly, especially dur- 

Danger from suppuration. ... 

ing lymg-m, and symptoms of adynamia, and 
decomposition of that fluid, are present, there is danger from 
purulent infection and infiltration. Other things equal, the more 
depraved the state of the blood, the greater the danger from 
ovarian abscess. If the formation of the "pus cavity" is slower, 
and its secretion more benign in character, and more especially if 
adhesive inflammation has served to protect the adjacent viscera 
bm implication, and to afford a means of final discharge, the 



746 THE DISEASES OF WOMEN. 

case may terminate favorably. Sometimes a period of months, or 
even years, is consumed in this critical process. If the case 
becomes tliiis chronic, there is danger from exhaustion, caused 
by the drainage of the patient's nervous energies and nutritive 
resources. This is especially true of scrofulous subjects, who 
present a cachectic appearance, and finally succumb to vital losses 
of this character. Becquerel* reports the case of a young woman 
of twenty-three years, in which death followed the discharge of" 
an ovarian abscess into the rectum. Kiwisch says, (op. cit. p. 86) : 

" The course o± these pelvic tumors is various. In favorable 
cases, the tumor, and with it all uncomfortable 'symptoms, com- 
pletely disappears, after a duration of some weeks or months. We 
have observed tumors the size of an adult head, exceedingly hard, 
and apparently in direct contact with the external abdominal 
integument, terminate' in that manner. In other cases, suppura- 
tion extends, and perforation takes place in various parts of the 
surrounding structures, finally terminating favorably. On the 
contrary, when the course is unfavorable, the continued or relaps- 
ing acute attacks, or the profuse suppuration, or the dissolution of 
these tumors, causes the exhaustion of the patient. A rare, fatal 
termination happened to us in one case, from strangulation of the 
adherent small intestine, two convolutions of which, strongly dis- 
tended by gas, burst spontaneously, during violent contraction.'' 

A spontaneous removal of ovarian tumors of various kinds, inci' 
dent to the inflammatory process, sometimes occurs. This may 
take' place even when the tumor has become so 
tumors lution ° f ovarian large as to be pushed out of the lower pelvis. 
in order that it may have sufficient room for 
development, as happens with the uterus, or at about the fourth 
month. Dr. Meigsf relates several cases in illustration of this 
fact, from which we select the following : 

" May 23, 1852. I this day examined the hypogastric region of 
Miss M. This lady, who has a very great spinal curvature, wag 
examined by me about nineteen or twenty months since. I then 
found a very solid, incompressible, and immovable tumor, large a? 
a child's head at term, which occupied the hypogastric region, 
and which was not a womb. It appeared to come up out of the 

* Traite Clinique des Maladies de l'Uterus et de Ses Annexes, Paris, 1859. Tom. 
II ; p. 476. 

f Woman, her Diseases and Remedies. Phila., 1859 , p. 357. 



OVARITIS 74? 

pelvis. I considered it to be an ovarian tumor — and, of course, 
my opinion was, that it was incurable, and must, in the course of 
time, destroy her life. To-day, no trace of it is discoverable — 
nor is there any reason to suppose it exists. I take comfort from 
this example — one of the most extraordinary I have met with — 
for all future cases of a similar character. I am wholly at a loss, 
to account for its disappearance, since I am sure it was not a 
hypertrophied womb that I detected nineteen months ago — and 
that it was not any glandular or hygromatous tumor. She is well 
in February, 1859." 

Apart from the danger from rupture and discharge of its con- 
tents into the abdominal cavity, from the pressure and weight of 

the tumor when very large, and the drain 
ch?r r ^ n fr ° m excessive dis " u P on tne patient's strength to nourish and 

sustain the mass, some allowance should be 
made for the liability to recurrent attacks of peritonitis, which 
always imperil the life of the patient. The same may be said of 
co-existing lesions of adjacent organs. 

Adhesions, resulting from the formation of adventitious mem- 
branes are not more dangerous than those which are incident to 

other serous tissues when inflamed — as, for 
consequences of structu- example, the tunica vaginalis testis, or the 

ral change. 1 ' o 

pleura. They may take place in consequence 
of a slight attack of ovaritis, usually styled " menstrual colic,' 1 in 
the newly-married female, or from metastasis of mumps to the 
ovaries, as happens to the testicle in the male subject, without any 
untoward results. This remark applies also to simple hypertro- 
phy, atrophy, and induration of the ovaries. 

Cancerous, calcareous, cartilaginous, and tuberculous degenera- 
tion of the ovary necessitates an unfavorable prognosis — unless, 
indeed, the surgical expedient of excision may promise somewhat 
of good. 

Sequelae. — Besides the lesions already spoken of as incident to 
ovaritis, there are others that should not be overlooked. 

These are chiefly related to the functions of menstruation and 

generation. Menstrual derangements are very liable to follow 

ovaritis, whether it involves the follicular or 

Menstrual sequelae. . _ , -. r 

the peripheral structure of the ovary. Many 
examples of amenorrhea, dysmenorrhoea, and menorrhagia, are 



748 THE DISEASES OF WOMEN. 

to be regarded as sequelse to attacks of ovaritis, the more evident 
symptoms of which may long since have passed away. The tex- 
tural changes detailed when treating of the pathological anatomy 
of this disease, are sufficient to explain the menstrual sequelae 
which are so often entailed upon the patient. It would not be 
reasonable to expect that the delicate process of evolution could 
proceed in an uninterrupted, physiological manner, after the 
Graafian vesicles had once been transformed into hsematic, serous 
or purulent cysts, and their walls hypertrophied, ruptured, or cica- 
trized. If blood or pus have infiltrated the stroma, or pseudo- 
membranous adhesions attached the organ to neighboring viscera ; 
if the fimbriated extremity of the Fallopian tube is bound down 
to the ovary, and that portion of the generative intestine occluded, 
the menses will either be entirely suppressed, or their escape and 
discharge become painful, scanty, insufficient, irregular, or too 
frequent and profuse. 

Nor are the evil results of these ovarian lesions limited to the 

ovaries. The intimate sympathy existing between these organs 

and the uterine mucous membrane is certain to 

implication of the uterine i m pii cate the i a tter in whatever pathological 

mucous membrane. -l jr o 

process affects the former, With each return 
of the catamenial period — no matter whether all its phenomena 
are present or not — this mucous membrane becomes highly 
injected and very vascular. If the proper flow is established, &l 
the proper time, and in proper quantity, this physiological 3iflu> 
of blood is quietly remedied and removed, as in the case of cthe* 
mucous membranes after their secretions have been poured out 
On the contrary, if the natural stimulus, originating in the ovary, 
is withheld, or perverted in its action or qualities, uterine de- 
rangements are a necessary consequence. Hence the intractable, 
nature of many examples of sub-acute and chronic metritis. 
Moreover, a long chapter of reflex disorders may be indirectly 
due to the same cause. 

I am inclined to the opinion that, as a sequel to ovarian inflam- 
mation, sterility is more frequently met with than is generalb 
supposed. The history of menstrual disorders 

Sterility from ovaritis. ... ,.,. ,-. -, -, . r» xi * 

and irregularities, just alluded to, connrms tnis 
idea. Indeed, whatever imperils the integrity of the catamenial 
function may also implicate fecundity. When lesions of the ova- 



OVARITIS. 74^ 

xies are sufficient to prevent the completion of the process of ovu- 
lation, they also prevent conception. If inflammation of both 
ovaries were as common as that of a single one, sterility would be 
as familiar a complaint as almost any other. As it is, while one 
of them escapes, other things equal, the power to procreate is 
continued, by a species of compensatory relation, as in the case of 
the male, when one of the testicles is diseased or has been re- 
moved. Induration of both ovaries, when it occurs in conse- 
quence of disease, is as inevitable a cause as atrophy from old 
age. The ovaries may be so displaced as to remove them from 
the reach and grasp of the fimbriae of the Fallopian tubes. In this, 
case they would have no communication with the uterine cavity ; 
and if the ovum were furnished by the follicle, it could not be 
conveyed to the womb. Sometimes, as a result of ovarian disor- 
ganization, diseased and imperfect ova are formed and furnished 
by the female. These may be impregnated, but subsequently are 
imperfectly developed, and abortion is a natural and necessary 
consequence. Hyperplastic formations and adhesions about the 
ovary may interfere mechanically to prevent conception, in some 
such manner as an excessive deposit of fat in the omentum some- 
times prevents women, who are remarkable for their pinguidity,. 
from having children. 

Sterility is not an uncommon sequel to gonorrhoeal ovaritis. A 
moment's reflection will convince you that this variety of the dis- 
ease under consideration is more likely to affect 
rhSa r i r ovar?tis fr ° m s ° nor * Dotn o™ r ies at the same time than any other, 
not even excepting the puerperal form. The 
lesion resulting therefrom may involve the most serious conse- 
quences to the generative function. Hence sterility not unfre- 
quently follows an attack of gonorrhoea ; and those who have had 
gonorrhoea repeatedly, are not apt to become pregnant. Without 
doubt, this result is sometimes chargeable to the blighting effects 
of the specific virus upon the ova, which it destroys in some such 
manner as it does the vivifying influence of the spermatozoa in 
the semen masculinum. But I apprehend that, in the majority of 
cases, actual lesions of the ovary are produced by the modified 
inflammatory process, which lesions are sufficient to account for 
the sterility that follows. 

Bernutz styles ovaritis " female orchitis." In the male sub- 



750 THE DISEASES OF WOMEN. 

ject inflammation of the testicle, accompanying or following a 
severe attack of gonorrhoea, may, and I believe frequently does, 
prove itself a cause of sterility. The same remark applies to those 
women who, having suffered from this form of ovaritis, find them- 
selves barren in consequence. 

My professional experience confirms this view. Physicians are 
often consulted for the cure of sterility in the persons of women 
whose husbands have been wild and profligate in youth, and 
whose bad habits may have perpetuated themselves. Careful 
inquiry into the history of such a case, may disclose that the 
patient has had one or more attacks of gonorrhceal ovaritis, from 
which, indeed, she may be suffering at the moment of consulta- 
tion. It is more than probable that such examples of ovaritis are 
modified by the specific gonorrhceal taint, however faint the im- 
pression and remote its cause. This clinical fact affords a plaus- 
ible explanation of the source of difficulties among the higher 
families and orders of society, on account of their lack of progeny, 
with which history and human experience abound. 

Although it may doubtless be true that, in exceptional cases, 
nymphomania results from ovaritis, yet experience has demon- 
strated that the most common effect of the dis- 
Nymphomania from ease j s ^ Q diminish rather than increase the 

ovaritis. 

sexual feeling. Dr. Ashwell* says: "In two 
instances, I am perfectly convinced that the result of the malady 
was entire aversion to intercourse, and it is now allowed that 
nymphomania more generally depends upon the external organs, 
so far as physical causes are concerned." 

Treatment. — This is divided into general and local. Owing to 
the present imperfect state of the materia medica, the pathoge- 
netic indications for remedies in the treatment 

General treatment. . , . . 

oi ovaritis are neither very explicit nor very 
numerous. Its special therapeutics must, therefore, be founded 
upon our knowledge of its pathology, the proper use of such 
provings as we have at command, the similarity of textures impli- 
cated in this and other well-known diseases, and the results of 
clinical experience. 

In the puerperal form, when the attack comes on a few days 

* A Practical Treatise on the Diseases peculiar to Women. Phila., 1855 ; p. 445. 



OVARITIS. 751 

after delivery, and the symptoms are those of surgical fever, 
with pain in one or both ovaries, and violent 
ovIrkf s tmentofpuerperal constitutional disturbance, aconite and arnica 
may be given for some hours, in rapid alterna- 
tion. If not of traumatic origin, belladonna may be substituted 
for the arnica. 

The symptoms and conditions which indicate belladonna, deserve 

especial mention. It is particularly adapted to the early stage of 

peritoneal inflammation, where the pains are 

Belladonna. . . . 

circumscribed and stabbing in character, or dart- 
ing, lancinating, and such as mark the acute stage of inflammation 
in other serous tissues — as, for example, in the arachnoid mem- 
brane. The diffuse peritonitis that sometimes supervenes, may 
also require the same remedy. If the attack occurs in conse- 
quence of taking cold, or is erysipelatous in character, belladonna 
is strongly indicated. The same is true of great cerebral disturb- 
ance, delirium, insomnia, dilated pupils, also of hysterical com- 
plications, neuralgia, and spasms. 

If the attack is ushered in by marked symptoms of local con- 
gestion, this remedy is particularly appropriate. This is true of 
the idiopathic, as well as of the post-partum varieties. In many 
sub-acute cases, aggravated at each menstrual period, the bella- 
donna may be given for a few hours with manifest advantage. If 
the pain is somewhat neuralgic in character, it may be equally 
useful. 

Next to belladonna, in the treatment of peritoneal ovaritis, 

colocynth, I am persuaded, is more useful than any other remedy. 

This is most marked in ovaritis supervening 

Colocynth. . . r ° 

upon abortion. 1 am anxious that you should 
not forget this fact. In this connection it is too frequently over- 
looked. You will find the symptoms that indicate colocyntn 
detailed in the materia medica. It is especially appropriate to 
those cases in which the bowels, and indeed the whole abdominal 
contents, are implicated, with stitches in the ovaries, diarrhoea, 
colic, pressure in the abdomen, suppression of the lochia, and 
tenesmus. Also in puerperal fever after vexation. Colocynth is 
recommended by some authorities for chronic ovaritis. 

The good repute of veratrum viride in puerperal metritis, its 
apparent capability of restoring the lacteal secretion and the 



752 THE DISEASES OF WOMEN. 

lochia, when they have been suppressed by the inflammatory pro- 
cess, renders it probable that this agent is pos- 
sessed of some specific relation to the ovaries. 
As a remedy in ovaritis, it should be given in an early stage of the 
disease, when the organism is most perturbed by reason of vascu- 
lar and nervous derangement. 

Mercurius vivus is useful at a more advanced period, more espe- 
cially, it is said, when there is reason to apprehend that suppura- 
tion may occur. Many practitioners rely chiefly 
upon this remedy in alternation with belladonna. 
The symptoms, mostly abdominal and symptomatic, which indicate 
mercurius vivus need not be detailed in this connection. 

During the summer term of lectures in this college for the year 
1864,* I called attention to the efficacy of the hamamelis virginica 
in ovaritis. The remarkable effects of this rem- 
edy, locally and internally, in orchitis, led me to 
infer that it would also be useful in some forms of ovaritis. I 
have prescribed it in numerous cases with remarkable results. It 
seems appropriate to the sub-acute attacks of this disease, which 
are incident to pregnancy and menstruation. In the former case, 
I have no question of its power, in some instances, to prevent 
abortion, where such a mishap threatens in consequence of ovarian 
irritation and inflammation. In the latter, it allaj^s the pain and 
averts the menstrual derangement which is so liable to follow. It 
is also useful in gonorrhoeal ovaritis, in which variety the suffering 
is sometimes extreme. This affection bears a close analogy to the 
gonorrhoeal orchitis of the male, in which hamamelis is almost spe- 
cific. For internal use, I prefer the second or third attenuation. 
The lauded virtues of gelseminum in gonorrhoea and sperma- 
torrhoea of male subjects, suggest that it might 
also be useful in ovaritis. The same is true of 
its power to excite uterine muscular contractility, and to allay 
hysterical spasms. 

Lachesis is indicated in ovaritis accompanying scanty, tardy, 
irregular menstruation, vicarious leucorrheea, and menstrual de- 
rangement incident to the critical period. When 

Lachesis. ..-.., ... , -. -. 

conjoined with metritis, in sub-acute and chronic 
cases, this remedy is sometimes very useful. It is recommend^ 

* See Medical Investigator, Vol. Ill, p. 62. 



OVARITIS. 753 

lay Hering in chronic enlargement with induration or abscess of 
the ovaries. The following cases were kindly furnished by my 
friend, Dr. A. H. Botsford, of Grand Rapids, Michigan : 

" Miss M — — had suffered many months from dysmenorrhea, 
with scanty menstruation. She complained of great tenderness 
in the iliac region, sometimes on both sides, and at others only on 
one, and I remarked a fullness in the region of the ovaria, when 
felt through the abdominal walls. She was so lame and sore that 
she could not walk. The attacks would culminate in a diarrhoea, 
the discharges having all the appearance of pus. Under the use 
of lachesis she gradually improved. Indeed it never failed to 
relieve her most signally, and the early employment of it invaria- 
bly prevented the recurrence of the acute symptoms and of the 
purulent discharge by the rectum. This patient ceased to men- 
struate at twenty-seven or twenty-eight years of age, and had no 
further trouble of the kind. She died at thirty-five, of pulmonary 
congestion. 

" Mrs. B , aged about 35, came under my care five years 

since. Ten years ago she was ill during the whole summer, with 
pain, soreness and swelling in the region of the ovaries. Is of 
opinion that she recovered in spite of medicine. She had chronic 
diarrhoea, with stools like 'matter, as if from a boil.' She had 
also an abscess communicating with one of the intercostal cartil- 
ages on the left side of the thorax. I gave her lachesis and hama- 
melis. She was very soon relieved, and now keeps the medicine 
within reach. She has no family. Menstruation is regular, but 
she is liable to acute attacks of ovaritis with each monthly return, 
especially if she overworks or is much fatigued." 

In frail, scrofulous subjects, predisposed to excessive purulent . 
discharges, these ovarian abscesses sometimes secrete an enormous 
amount, and for a long time. This drain produces a species of 
cachexia in which other remedies may also be of service. The 
hepar sulphuris, calcarea carbonica, china, and phosphoric acid 
have been recommended to meet this indication. 

Bryonia does not appear to be so well adapted to inflammation 

of the peritoneum as to that of some other serous tissues — as, for 

example, the pleura and synovial membranes. 

Bryonia alba. op 'j. 1 '£1 

So far as we are aware, it has no specmc rela- 
tion to the ovary. In the puerperal form of ovaritis, where the 

48 



754 THE DISEASES OF WOMEN. 

attack sets in with chilliness and rigors, and especially in case of 
threatened mammary abscess, the breast being large, hard, tense 
and painful, it may, however, be very useful as an intercurrent 
remedy. We have sometimes employed it with advantage in 
rheumatic ovaritis. The same remarks apply to the rhus toxico- 
dendron and the cimicifuga or macro tys. 

The ovnlar theory of menstruation is confirmed by clinical 

experience. Excepting those already named, and a few others 

which are given for specific reasons, all the 

The menstrual disorder 

aids m choice of the rem- remedies or considerable repute, in the treat- 
ment of sub-acute and chronic ovaritis, have 
been prescribed for the relief of menstrual irregularities. More- 
over, it is especially significant that each of these remedies is said 
to have caused abortion, a fact which confirms the idea advanced 
by Tyler Smith, that the specific stimulus of uterine contraction 
resides in, or must operate through, the ovaries. From these 
observations, certain therapeutical deductions are obvious. There 
is no question but that many examples of ovaritis, complicated 
with catamenial derangement, have been unwittingly cured by 
secale cornutum, sabina, apis mellifica, pulsatilla, sepia, platina, 
cantharis, and caulophyllin. The best criteria for, the use of these 
remedies in ovaritis, will be found in their adaptation to menstrual 
disorders, as amenorrhcea, dysmenorrhoea, menorrhagia, and also, 
in many cases, to leucorrhcea. 

Ovaritis, complicated with ulceration of the os uteri, requires 
to be treated most carefully. A resort to astringent injections, or 
cauterization, is too frequently had, by those who covet notoriety, 
and are reckless of consequences. The proper constitutional and 
local treatment for uterine ulceration will be detailed in a subse- 
quent lecture. 

For atrophy and induration of the ovaries, with which sterility 
is almost always associated, jodium, conium, plumbum and baryta 
muriatica, are in good repute. Change of air, 
atrcpTyT^dSnLrrdoiT 11 an( ^ diet, trave l & n & diversity of scenery, are 
sometimes of lasting benefit. I have succeeded 
in curing one case of barrenness, in which there was chronic indu- 
ration and insensibility of both ovaries, with an almost total atre- 
sia of the canal of the uterine cervix. This canal was dilated 
artificially, while, at the same time, remedies were given to restore 



OVARITIS. 70J 

the menstrual process. Conception followed, and the ovarian lesion 
disappeared. 

When there is reason to suspect that either the gonorrhoeal or 

syphilitic taint is present, the mercurius solubil- 

ovIr?tfs tmentfors ° norrh<Eal is ' mercurius jodatus, nitric acid, thuja, kali 

jodatum, or aurum metallicum, may be indicated. 

The curative virtue of calendula would be available in case of 

fistulous opening and discharge of the ovarian 

abscess through the abdominal walls, or into the 

bowel, bladder, uterus, or vagina. 

In puerperal ovaritis, when the inflammation and tenderness 
become diffuse and very acute, I know of no local expedient so 
grateful and beneficial, in a majority of cases, 
as the application of dry, hot bran to the abdo- 
men. It should be sewed up in bags, heated as hot as can be 
borne, applied, and then renewed frequently. This application 
possesses the merit of availability and lightness ; it is inodorous, 
and medically unobjectionable. 

After the acute symptoms have yielded somewhat, and the 
patient is able to lie upon her side, dry heat may still be used, by 
means of a heated dinner plate, which is Avrapt in flannel and 
kept in constant contact with the abdominal parietes. Cloths 
clipped in hot water soon become cold, and the patient may be 
chilled thereby. Hops are sometimes prescribed in extreme cases, 
in which it is impossible for the patient to sleep, and where nerv- 
ous symptoms predominate. Emollient cataplasms of various kinds 
have been resorted to, and sometimes with good results. 

In acute ovaritis, where the pain is more circumscribed and very 

severe, arising, propablv, as M. Velpeau suggests is the case in 

orchitis, from strangulation of the organ by its 

Hamamelis virginica. , 

envelop, great reliei may be attorned b} r the 
external use of the hamamelis virginica. I prefer Halsey's fluid 
extract of this drug, which may be mixed with hot water, in the 
proportion of one part to three, and applied locally, by means of 
cloths or flannels that have been dipped therein. In case the 
swollen and sensitive organ is prolapsed along the wall of the 
vagina, a weaker solution of the hamamelis, containing glycerine, 
may be used as a vaginal injection, or applied by means of cotton 
wool or charpie saturated with the same, and introduced into the 



75<) THE DISEASES OF WOMEN. 

vagina. This application is sometimes remarkably efficacious. Ife 
may also be injected into the rectum. If the 

Arnica— Aconite. . . . 

inflammation is of traumatic origin, arnica may 
be used in the same manner as recommended for the hamamelis. 
The local and general employment of aconite is recommended in 
case of a rheumatic complication, which sometimes involves the 
most extreme suffering. 

Vicissitudes of weather and temperature sometimes affect this 
class of cases so unfavorably, that it is well to protect and insulate 

the ovaries from their harmful influence. For 
dampnS. from cold and tnis purpose a layer of cotton batting, flannel, 

or silk, should be worn next the abdomen. In 
very susceptible subjects, where, from taking cold, mild attacks of 
ovaritis frequently accompany menstruation, this expedient is also 
serviceable. 

Warm baths are better than cold, and the hip bath is preferable 
to any other. The cold hip bath is sometimes useful, but should 

be taken quickly, in order to insure reaction. 

They should not be used indiscriminately. For 
the relief of pelvic pains incident to severe attacks of ovaritis and 
ovarian neuralgia, Dr. Aran recommends the expedient of packing 
the speculum, in vagina, with coarsely powdered ice. Such ex- 
treme measures are rarely, if ever, justifiable. 

Little attention need be paid to restoring the displaced ovary. 
Remove the inflammation, and the structural changes consequent, 
upon it, and the dislocated ovary will take care of itself. Any 
attempt to reduce the luxation, farther than by placing the patient 
in a favorable position, would probably result in more of harm than 
of good. 

As one of the most trying obstacles in the way of a cure is found 
in the recurrent menstrual congestion ; so it is quite impossible, 

in many cases of ovaritis, to effect a cure while 
cours°e Cribe sexual inter ~ tlie patient yields to sexual indulgence. She 

must live absque marito. I have found that 
those patients with ovaritis who come to this city for treatment, 
and who are thus removed for a time from the stimulus of sexual 
excitement, recover more rapidly and permanently than others of 
my patients, who, while being treated, are obliged to remain at 
home. There are, however, a few exceptions to this rule. 



LECTUEE XLVI. 

OVARIAN NEURALGIA — OVARALGIA. 

X)varalaia. Etiology. Clinical history of. Diagnosis. Prognosis. Treatment. Ovarian 
Irritation. Case.— Causes, nature of. Case.— Remedies. 

An eminent author lias insisted that the ovarian stroma is the 
sexual center of the female organization. Whether or not this 
theory is true, it is certain that this spongy structure is erectile, 
and therefore subject to extreme vicissitudes in respect of its cir- 
culation and innervation. For the ovaries are well furnished with 
blood vessels and nerves. This is a necessary condition of their 
functional activity which, as in the case of other delicate organs, 
implies the possibilities of diseased states that shall arise from a 
derangement in their nutritive and nervous supply. 

In health the ovaries are not sensitive. Enclosed in their fibrous 
capsule (tunica albuginea,) they float out of harm's way. But, 
under some peculiar or periodical excitement of 
ovLTan^mtSfon 1301161115 ^ tne generative system, as, for example, in coitus, 
menstruation, pregnancy, or parturition, they 
are liable to become irritated, congested, inflamed, or the seat of 
severe neuralgic pain. And since " women are always about to 
menstruate, or menstruating, or ceasing to menstruate ; or the 
womb is gravid or going to become so, or it is recovering from 
the parturient state ; these organs have never an even, steady 
tenor of life." Hence the frequency of ovarian diseases, one of 
the most interesting and troublesome of which is the theme of my 
lecture this morning. 

Etiology. — ■ The neuralgic diathesis is the most powerful predis- 

ponent of ovaralgia. Women Avho are subject to neuralgia of the 

face, head, teeth, and other parts, sometimes 

The neuralgic diathesis. 

suffer severely from this affection. In such 
persons, if anything is wrong in the pelvic region, the pain is very 
liable to become neuralgic, in which case the rectum, the uterus, 
the neck of the bladder, or either of the ovaries, may be the seat 



758 THE DISEASES OF WOMEN. 

of suffering. In this class of subjects the nervous system may have 
been originally weak and subject to painful disorders, or that con- 
dition has, perhaps, been acquired by habits of life, and the sur- 
roundings to which the patient has been subjected. We find 
examples of this kind among seamstresses, who lead lives of ^oil 
and anxiety, and who subsist upon tea, with insufficient and 
improper food, as well as among those who are buffeted by 
emotional excitement at the expense of their happiness and 
general good health. Such persons are almost invariably anseniic 
or chlorotic. 

This neuralgic predisposition may be complicated with, a rheu- 
matic diathesis. I have treated several patients for neuralgia of 
the pelvic organs in whom the suffering was 

The rheumatic diathesis, -• . ■■ ■■ -it • p t i 

directly chargeable to a metastasis or the disease 
from some other part of the body. My own observation leads me 
to conclude that the daughters of rheumatic fathers, especially if 
the parent was of intemperate habits, are particularly liable to this 
complication. The rheumatic element may be masked, but it cer- 
tainly modifies the nature of the attack, and should not be over- 
looked in its treatment. 

So also of hysteria. Very few hysterical women are exempt 
from neuralgia. Indeed, it is one of the many peculiarities of 

hysteria, that the slightest causes implicate the 

The hysterical diathesis. -, • -, nr • ait 

nerve filaments and involve sintering. A local 
congestion which is temporary, incidental, and self-limited, and 
which in other persons would be an insignificant affair, in women 
of this temperament will sometimes give rise to extreme suffering 
of a neuralgic character. It is true that such patients are prone 
to exaggerate their sufferings, but still the fact remains, that in 
hysterical women the peripheral nerve filaments are peculiarly 
sensitive to causes which induce pain. 

The excitement of the generative system to which this class of 
persons is especially subject, is a fertile source of ovarian neural- 
gia. Excessive or fraudulent intercourse ; un- 

Sexual excitement. 1 

gratified sexual desire ; menstrual derange- 
ments ; emotional influences, as, for example, too much of thea- 
tre-going, of novel-reading, of dancing, or of the worry and wear 
of fashionable society ; carrying too much or too little weight in 
life, and exemption from proper household cares ; may cause sucli 



OVARIAN jXLUKALGIA. 759 

a determination of blood to the pelvic organs, and especially to 
the ovaries, as shall induce this form of neuralgia. 

The same is true of uterine displacements, organic disease of 

the ovaries and of the womb, of pregnancy, and of the parturient 

act. Or it may be caused by nervous shock, by 

Organic disease of uterus contusions or falls, the taking of long rides or 

and ovaries. " o o 

walks, lifting, jumping, singing, running the 
sewing machine, or, what is worse than any other form of exercise 
for a woman with intra-pelvic disease of almost any kind, the 
dressing of her own hair. 

Clinical History. — The attack comes on abruptly, and without 

premonition or apparent cause. Perhaps she is 

Mode of attack. r , tf t . . , 

seized while walking, or upon turning in the 

bed, upon stepping into her carriage, while sneezing or laughing, 

or, it may be, after the sexual act. 

The pain is acute, paroxysmal, and, contrary to the general rule 

in neuralgia, is increased by the- touch and by pressure, whether 

it is slightly or more firmly applied. Accord- 
Kind and degree of pain. . b J / . Ll 

ing to Churchill, the pain is generally much 

greater than that resulting from ovaritis. It rarely seizes both 
ovaries at once, but frequently alternates. It is described as sud- 
den, intense, excruciating, stabbing, cramp-like, and is apt to be 
accompanied by bending of the body toward the affected side, by 
fainting, falling, vomiting, hysterical spasms, delirium, or diuresis. 
Sometimes it radiates, and, in chronic cases (as also in those which 
occur in pregnancy), it may extend along the corresponding thigh. 
Usually, however, it is circumscribed and limited to the site of the 
ovary, which, as you know, varies in different women and at dif- 
ferent periods. 

It is not uncommon for the patient to describe the pain as ac- 
companied by a sensation as if something would burst in that 
locality. At other times she recognizes a sense 

Peculiar sensations. . „ 

of compression, of stricture, or 01 strangula- 
tion. Something upon which she puts the tips of her fingers feels 
as if tied up tightly. In some cases she cannot lie down, in others 
to stand is impossible. The pain remits, but does not, as a rule, 
pass away suddenly. The paroxysm is very liable to recur. 

When it occurs as a contingent of dysmenorrhcea, the pain is 
*' sickening " in character, and peculiarly distressing and exhaust- 



760 THE DISEASES OF WOMEN. 

ive. In this class of cases, Rigby says, the pain is chiefly confined 
to a spot about an inch above the middle of 
stmiidlsordSr 1 t0 men ~ Poupart's ligament, frequently extending to the 
back, and sometimes down the thigh. Ovarian 
neuralgia is more likely to set in at the very beginning of the 
period, than after the flow has commenced. It may recur in case 
the menses come on scantily for a few hours, or a day, and then 
stop for a little, and finally return more freely. This intermittent 
form of menstruation is very apt to be accompanied by more or 
less neuralgia of one or both ovaries, upon the existence of which, 
indeed, it may be dependent. For the neuralgia may cause the 
menstrual irregularity, and vice versa. 

An engorged state of the ovary is undoubtedly the source of 

suffering in this disease. From the afflux of blood to it, the substance 

of the organ becomes swollen. Its fibrous en- 

Cause of the pain. . n , 

velope being firm and resistant, limits the 
expansion of the erectile tissue which it contains, binds it down, 
compresses it, strangulates it, and intense pain is the direct and 
inevitable result. Whatever means are capable of relieving the 
congestion will put an end to the paroxysm. 

So likewise the existence of old, inflammatory .adhesions be- 
tween the ovaries and other pebvic viscera, may cause this spas- 
modic or congestive neuralgia, through a perma- 

Peritoneal adhesions. 

nent displacement 01 the organ. Such an at- 
tachment may be unnoticed and harmless until the period of preg- 
nancy has arrived, in which it is necessary that the ovary should 
ascend beside the womb above the superior strait. " If the peri- 
toneal adhesions be slight, they may perhaps get ruptured as the 
uterus enlarges ; the patient will suffer from severe hypogastric 
pains, especially during the second and third months, and there is 
sure to be very troublesome sickness."* But if these adhesions, 
which are sometimes strengthened by fibrous bands and exuda- 
tions, that have cemented the ovary very firmly, are not broken, 
the suffering may either persist to term or it may result in abor- 
tion. 

Diagnosis. — -You can diagnosticate ovaralgia from ovaritis by 
the absence of a chill, fever, or other constitutional symptoms at 

* Tanner, on the Signs and Diseases of Pregnancy. Phila., 1868 ; p. 239. 



OVARIAN NEURALGIA. 7*3 1 

the outset ; by the suddenness of the attack ; the intensity of the 
pain, which is limited to a small extent of sur- 

From ovaritis. 

face ; by the acuteness and brevity of the par- 
oxysm ; the absence of burning pain in the affected part ; by the 
fact that it occurs most frequently in nervous, hysterical persons ; 
by the self-limited nature of the disease ; and its different modes 
of termination. 

The location of the tumor (in case the ovary is very much 

swollen), the kind of pain complained of, the lack of impulse in 

the tumor when the patient coughs, its occur - 

From hernia. . 

rence in one oi a neuralgic diathesis, and the 
impracticability of taxis, would differentiate the worst case of 
ovarialgia from all forms of enterocele. 

In neuralgia of the womb the pain extends over a larger sur- 
face, is more marked in the hypogastric than in the iliac regions, 
never alternates between the two sides of the 

From uterine neuralgia. . . 1 . _ 

pelvis or abdomen, is less sudden in the begin- 
ning, and less excruciating in degree, seldom follows the course 
of the sciatic nerves, and is not so apt to leave abruptly as in 
ovarialgia. 

Prognosis. — This is generally favorable. No one ever dies 
directly of ovarian neuralgia, any more than from its more ordi- 

dinary forms. It may, however, through its 

Indirect results. . . 

persistence and severity, induce such diseases 
of the ovaries, or of the uterus, or of both, as will ultimately give 
rise to very serious consequences. Or, in a reflex way, it may 
light up and perpetuate such sympathetic disorders of the heart, 
of the lungs or even of the brain, as eventually will terminate dis- 
astrously. 

It is not always safe to promise a radical cure. Rheumatic and 
hysterical complications are tedious and intractable. The same 

is true of the contingent irregularities of men- 

Quahfy your prognosis. • i_ ■ j? M. • T^n 

struation. In most cases, m briei, it is so aim- 
-cult to control the patient's habits and surroundings, as well as the 
emotional and sexual influences to which she is subjected, that we 
can only hope to afford temporary relief. 

When it occurs during pregnancy, this painful affection is self- 
limited, generally disappearing after labor. If, however, the 
-adhesions have prevented the ascent and development of the 



762 THE DISEASES OF WOMEN. 

gravid uterus, there is danger of abortion, in which case the risks 
of premature delivery are added to those of the neuralgia. 

Treatment. — The preventive treatment of this disease is very 
important. It consists in removing all causes of undue sexual 
irritation and perturbation ; in regulating the 
kind and degree of exercise to be taken ; in 
changing, if need be, the whole mode of life and habits of the 
patient, and in curing the diseased conditions upon which this 
painful affection may depend. Among the items which come 
under the latter head, none is more prominent and practical than 
to order such a diet and such general hygienic relations as will 
improve the quality of the blood. In neuralgia, nutrition is very 
apt to be impaired. There exists anaemia, or the woman is chlo- 
rotic, and while this state of things continues, a cure is impossible. 
If we would restore those who are ill to their wonted health, it is 
our first duty to supply the conditions upon which health 
depends. 

Milk is the best standard for blood, and should be used, in one 
form or another, by this class of patients. The whites of eggs, 
lean meats, game, salt water food, and vege- 
tables, afford a list from which to select what is 
palatable and nutritious. The diet should be varied from time to 
time. If the appetite has failed it may be stimulated by the tem- 
porary use of pepsin, as sold in the shops, by the extract of malt, 
or by the taking of malt liquors in small quantities. 

If the disease is complicated with rheumatism, great care should 
be taken to protect against vicissitudes of weather, and especially 
against taking cold. As a precautionary meas- 



„ & — ^^~ — — & 

rheumatic com- -y 
plications 



For the rheumatic com- ure f ^ s k mc i ? I have sometimes directed my 



patients to wear two or three layers of flannel 
over the abdominal and hypogastric regions, in the form of an 
apron applied directly to the integument. A batch of uncarded 
cotton may be sewed into the clothing and worn in a similar 
manner. The feet should always be kept dry and warm, but more 
especially "at the month." Because of the erratic nature of the 
disease, and its liability to metastasis to the ovary, you should 
remember that revulsive applications to the seat of rheumatic in- 
flammation, when it is located in other parts of the body, are par- 
ticularly hazardous in the case of women who are subject to sexual 



OVARIAN NEURALGIA. 765 

derangements. The same is true of the use of the ointments 
which are sometimes prescribed for cutaneous eruptions. 

During the paroxysm we must institute measures to relieve the 

suffering as speedily and safely as possible. In every variety of 

acute painful disorder which is located in the 

Palliatives. . , . . 

uterine or the ovarian regions, warm applica- 
tions are more grateful and soothing than such as are either cool 

or cold. This is especially true in case of intra- 
thln a cSd applicati ° ns better P eiv i° neuralgia, upon which the warmth seems 

to act as a species of anodyne. Aran's expe- 
dient of introducing the speculum, and filling it with powdered 
ice for the relief of ovarialgia, is too harsh, and might be indi- 
rectly injurious. 

Acting upon the clinical hint that warmth is better than cold, 
we may order the application of flannels or towels that have been 

dipped in hot water, or of dry heat in some 

Topical expedients. -i i i p -i • 

available form, directly to the seat ot the pain. 
If the suffering is of traumatic origin, one part of the tincture of 
arnica may be added to ten of hot water and applied locally. If 
ft is rheumatic, the extract or the tincture of hamamelis, or of 
aconite, may be used in the same manner. Or the same sub- 
stances mixed with warm Avater and glycerine, may be thrown 
into the rectum or into the vagina. If the attack is incident to 
dysmenorrhcea, the warm sitz-bath may be serviceable. 

Sometimes the pain will be made to vanish by the topical appli- 
cation of the strong tincture of the aconite root. Or a very little 
veratrin dissolved in glycerine, or mixed with simple cerate, may 
be rubbed in gently. A mixture, consisting of chloroform one 
drachm, and olive oil and glycerine each one ounce, may be ap- 
plied to the integument covering the tender ovary, or, better still, 
introduced into the vagina, by means of a cotton tampon which is 
saturated with it. A thread should be attached to the tampon to 
facilitate its removal. It may be allowed to remain for some 
hours. An injection of the same substances may be thrown into 
the rectum. You should remember, however, that, owing to con- 
tiguity of structure, injections thrown into the rectum for the 
relief of ovarian pain, are much more useful and prompt in their 
action in affections of the left than of the right ovary. 

In exceptional cases the suffering depends on the presence of 



764 THE DISEASES OF WOMEN. 

dry, hard, fecal matters lodged in the rectum, and to unload the 
bowel affords immediate relief. In very severe 
laSnT^ fccal accumu " cases of ovarialgia, if the means were at hand, 
the ether spray might be applied to the iliac 
region with excellent effect. Unless complicated with hysterical 
spasms, general anaesthesia is not necessary. 

I know that these and kindred expedients are prohibited by 
some physicians, who insist that they are both unnecessary and 
harmful. But it is my duty as a teacher to acquaint you with 
resources that may be useful in emergencies, and which are some- 
times permissible on the score of humanity. It is for yourselves, 
and not for others, to say whether and how often you will employ 
them. 

Of the various internal remedies for ovarialgia, perhaps the 
valerianate of zinc is most frequently prescribed. It seems espe- 
cially adapted to the relief of the different 

\ T 3.lGricin.citc of zinc 

forms of neuralgia which are engrafted upon 
the hysterical constitution. For it obviously has some specific 
curative relation to the ovaries themselves, and through them, to 
the whole nervous organization of woman. It will sometimes put 
an end to the paroxysm at once, but its best effect is in prevent- 
ing a return of it. It may be given in the third decimal tritura- 
tion, and repeated from two to four times daily. If the patient 
has ovarian neuralgia before menstruation, she may anticipate its 
return and avert the suffering by taking a few doses of this 
remedy a day or two in advance of the period. 

Atropine is useful under the same indications for which bella- 
donna is generally given. In very severe attacks it may serve to 
stop the pain, quiet the nervous perturbation, 
and promote rest and sleep. The cases to which 
it is most appropriate are those in which there is a strong ten- 
dency to ovarian congestion, with intolerance of light and noise, 
dilatation of the pupils, and delirium ; also, when the ovarialgia 
is accompanied, as it sometimes is, by vaginismus. When the 
menstrual return is characterized by downward pressure of the 
uterus, as if it would be forced out at the vulva, and in conse- 
quence the patient is obliged to lie in bed for some days ; and 
when there are incidental paroxysms of acute pain in either 
ovary; this- remedy is almost specific. Two grains of the third 



OVARIAN NEURALGIA. 765 

trituration may be dissolved in half a glass of water and a tea- 
spoonful of the solution given every one to three or more hours. 
Or it may be given in small powders dry upon the tongue. In 
some cases, however, there is such a susceptibility to the action of 
atropine, that you will be obliged to substitute it with belladonna 
in a medium or higher potency. 

Colocynth is applicable to neuralgia in the inguinal region, with 
boring, tensive, or stitching pains in the ovary, in case the symp- 
toms resemble those of hernia, contractive pain 

Colocynth. . . . * 

in the stomach, with eructations, nausea, pallor, 
coolness of the extremities and cold sweat. Also if there is inci- 
dental colic, with disposition of the patient to bend herself double. 

Other remedies which may be useful are cantharis, coffea, 
chamomilla, cocculus, cuprum met., ignatia, platina, pulsatilla and 
sepia. For their special indications I must refer you to the 
materia medica. 

Dr. W. H. Holcombe reports* that, while giving naja to a very 

intelligent patient, a physician's wife, for organic disease of the 

heart, " she complained that it contained a 

Naja. / 

symptom altogether new to her — a violent, 
crampy pain in the region of the left ovary." " I met," he says, 
" a similar case a week afterwards, and gave naja, 3d. It was 
relieved immediately. I have verified its value several times. 
Not a month ago I had one of those severe cases of ovarian con- 
gestive neuralgia — for that is the best name I can^give it. It had 
resisted chamomilla and hyoscyamus, both at the 6th ; generally 
my first prescription. I was about to prescribe caprum metalli- 
cuni, 6th, (which is excellent in those cases), when the patient 
related the curious fact that she had violent palpitation of the 
heart whenever the ovarian pain came on. I gave naja, 3d, and 
both symptoms disappeared as if by magic." 

My friend, Dr. R. N. Foster, of this city, has confidence 
in the third decimal trituration of ammonium 

Ammonium muriaticam. 

muriatic urn. 
Those members of the class who attended the last meeting of 
the Chicago Academy of Medicine will recall 

Ignatia. ° J 

Dr. Ballard s report of a very interesting case 
of this disease in a pregnant woman. The affection occurred in 

* United States Medical and Surgical Journal, Vol. I, p. 234. 



766 THE DISEASES OF WOMEN. 

her first pregnancy, and was uncontrollable by the old fashioned 
means. She went through to term, however, without serious 
accident. In the second pregnancy the same symptoms came 
back again, and she suffered extremely. The paroxysms of pain, 
sometimes in one ovarian region and again in the other, came on 
almost daily. She was extremely nervous, with headache, and 
the slightest noise startled her. The doctor prescribed three 
powders of ignatia, 200th, one to be taken every night. The 
paroxysms immediately became less severe in degree, and less 
frequent, some weeks elapsing between them, and she got through 
safely, with much less suffering than before. 

If I may judge from my own observation, the cimiciluga is a 
good remedy for ovarian neuralgia occurring in rheumatic subjects. 
It seems also adapted to women of dark hair, 
eyes, and complexion, and to those who are the 
children of intemperate parents. In this latter class of subjects 
it is suited to the relief of contingent attacks of hysteria, dys- 
menorrhcea, intense reflex pains, as, for example, angina pectoris, 
or the characteristic infra- mammary pain in the left side of the 
chest. 

OVARIAN IRRITATION. 

Case. — Mrs. K , English, 54 years old, the mother of eight 

children, has been in poor health ever since her " change," which 
occurred seven years ago. Prior to that she had always enjoyed 
good health, although she confesses that she " was always very 
nervous." Once, however, she has had a pretty severe attack of 
gout in her right foot, and occasionally rheumatic lameness in her 
right arm. It was her habit, while she continued to menstruate 
to flow more freely than most women, and after the birth of some 
of her children she had severe haemorrhages. But, notwith- 
standing this, the climacteric passed without any flooding, or any 
dangerous symptoms whatever. The only complaint for some 
months after the flow had ceased was of a congestive headache, 
which alternated with a severe aching, sickening, burning pain in 
the left hypogastric and iliac regions. Finally the headache left, 
but the ovarian sufferings continued. 

For some weeks past she has been subject to occasional out- 
breaks of diarrhoea, which alternate with constipation, with scy- 
balous stools and cutting colicky pains in the abdomen. She is 
extremely nervous and excitable, has globus hystericus and very 
copious urination now and then, and rinds herself '" very uncer- 
tain." 



OVARIAN IRRITATION. 767 

On inspection the abdomen is uniformly distended. There is 
evident meteorism, which is general. Palpation does not disclose 
the presence of any tumor or enlargement. The left ovarian 
region is tender to the touch and to moderate pressure, but not 
especially so to firm pressure with the tips of the fingers. The 
os uteri is not abnormal. The uterus is in situ and mobile. The 
sound passes readily to the depth of two inches by actual meas- 
urement. Bi-manual examination does not reveal anything ab- 
normal. 

The subject of ovarian irritation, first described by Gooch, has 

-of late acquired a new interest. In 1878 Dr. Fothergill published 

a, very interesting and practical paper on a form of this affection 

which he termed ovarian dyspepsia. This is a 

Ovarian dyspepsia. „ ,. , . '■ , 

reflex disorder, as much so as the vomiting that 
is a constant symptom of a calculus in the pelvis of the kidney, 
or the cough of pregnancy, which is known in Scotland as " a 
cradle cough." It is the direct and immediate consequence of the 
ovarian irritation. Dr. Fothergill says : * 

"All who have seen much of practice are familiar with these 
trying cases, which seem to go on unaffected by remedial meas- 
ures, until the malady seems to wear itself out; to be suc- 
ceeded by a long and tedious convalescence. It would seem 
that at last the condition of general mal-nutrition starves down 
the congested ovary till it ceases to set up and send out those 
perturbative nerve-currents which excite the gastric disturbance. 
Then the stomach settles down and resumes its ordinary duties 
once more without disorder. The case lingers on unrelieved 
because its real pathology is not recognized. The stomach is 
treated, and not the ovary. The gastric disturbance is not prim- 
ary, but reflex. Its causation must be comprehended, and the 
treatment directed accordingly, and the improvement will follow. '' 

If your experience accords with my own, I think you will find 
that the class of subjects who suffer most from this peculiar form 
of ovarian irritation, are those who have been treated for alono* 
time, and by very harsh means, for an alleged ulceration of the 
cervix, and also those who are predisposed to phthisis. If you 
observe carefully, you will find that in chronic digestive disorders 
occurring in women who are advanced in their menstrual life, 
there is often a state of hyperemia of one or both the ovaries that 
Dr. Barnes has styled " oophoria" which needs o be relieved and 
cured before the gastric disorder will yield. 

Ovarian irritation is not an infrequent sequel to the climacteric, 

*The American Journal of Obstetrics, Etc., Vol. XI, page IT. 



768 THE DISEASES OF WOMEN. 



It is often the cause of ill health among those who, like this 
woman, have ceased to menstruate. But 

At the climacteric. . . 

there is a combination of circumstances which 
constitutes a strong predisponent to this affection in such persons, 
and which is well illustrated in the case before us. Her habit of 

menstruating very freely, while that function 

Complications. . 

was intact, and of flooding m childbed ; her 
rheumatic diathesis ; and her hysteric constitution, render it 
almost impossible for her to have escaped the disorder from which 
she is at this moment suffering. 

Fortunately, she did not experience any severe or alarming- 

haemorrhage at the menopause. In this respect the menstrual 

function ceased without any untoward symp- 

Analysis of the case. 

toms. In so tar, her case was an exception to the 
rule that the hemorrhagic diathesis predisposes to critical floodings, 
which may damage the general health, and endanger life. But 
this very exemption may have acted as an exciting cause, and 
prompted the development of the rheumatic and hysterical ten- 
dencies. As a matter of course, under these peculiar circum- 
stances, the ovary (and the left ovary especially) would be more 
liable to implication than any other organ. 

Hence a train of symptoms that are compounded of hysteria 
and rheumatism. If, instead of being predisposed to these affections, 
she had had a constitutional bias toward cancer, 
dropsy, or tuberculosis, the result would have 
been very different, and the case would probably have developed 
into one of cancer of the womb, or of the mammary gland, or she 
would most likely have had an ovarian cyst, or some form of 
phthisis. 

You can scarcely err in ascribing a sickening, burning pain, 
with aching in either of the iliac regions, to irritation or inflam- 
mation of the ovary. No matter what other 

A pathognomonic sign. . . 

symptoms are superadded, if this is irequent 
or constant, the primary lesion is in that organ. The patient may 
have any of the manifold signs of hysteria, or she may have indi- 
gestion and diarrhoea, or constipation, or all these in alternation, 
and yet the focal point of the disorder will be either in one or in 
both the ovaries. 

Among the exciting causes of ovarian irritation which we have 



— 



OVARIAN IRRITATION. 769 

not already enumerated, are the indulgence of such habits, and 
the subjection to such emotional influences as 

Exciting causes. .. . 

tend to derange the circulation and innerva- 
tion of the generative organs. One of my patients had this 
disorder in a most intractable form in consequence of taking 
vaginal injections of cold water, and sometimes of ice-water, 
several times daily for more than two years. In another it was 
caused by horseback riding. It frequently originates in the 
sudden arrest of a leucorrhceal discharge by astringent injections. 
A fertile source of this affection is the habit of staying at home, 
and of going very little into the open air ; for, contrary to what 
you would suppose, nothing allays a sur-excitation of the female 
sexual system like exercise or exposure out of doors. 

In order to show you how these simple causes operate, and how 
complicated the resulting affections sometimes are, I will read 
you the notes of a case in which I was recently consulted by 
my friend and former pupil, Dr. A. W. Woodward, of this city, 
who has reported its history for me : 

Case. — Mrs. B , a middle-aged, slender, and somewhat 

delicate woman, with three children, has usually enjoyed good 
health. During the last few months she has been too closely 
confined with family cares, and spent too many hours at the sew- 
ing machine. In consequence, she began to be troubled with a 
more or less severe pain, sometimes acute in character, located in 
the left hypogastrium. This pain is aggravated by standing upon 
the feet for any considerable time, and is much more severe and 
continuous just before the menses. It extends through the whole 
length of the left limb. The flow had always been normal until 
within the last two months, since which time it has been both 
protracted and profuse. 

A lady practitioner diagnosticated "retroversion and prolap- 
sus," and treated her by a severe and prolonged application of gal- 
vano-electricity. As a consequence the patient was completely 
prostrated, the pain was greatly increased, and instead of being 
merely indisposed, she became quite ill. At this stage I was called 
in, and finding no signs either of retroversion or of prolapsus, or 
of anything to contra-indicate the use of stimulants, they were 
given, with good effect. Hot fomentations relieved the pain, and 
as this subsided it was followed by a copious diuresis, for which I 
gave ignatia. 

This remedy was continued until the next day, when I found 
her with heat and slight swelling in the region of the left ovary 

49 



770 THE DISEASES OF WOMEN. 

a rapid pulse, thirst and headache. The pain still continued, but 
was throbbing and not of the " sickening" kind that she had had 
before. I prescribed atropine and mercurius sol., and although 
she had a marked chill followed by heat during the afternoon, 
these remedies were given until the next morning. Arsenicum 
caused the strength to return, the pain to be lessened, and there 
was no sign of a chill for several days. 

But as the ovarian difficulty subsided, the stomach began to be 
deranged. At different times anorexia, cramps, acid eructations 
and vomiting were present. The symptoms would yield very 
readily to mix vomica, and then be followed either by a return of 
the ovarian irritation, by diarrhoea, or by a chill, after which these 
different affections would terminate with a profuse flow of urine: 
Then the same series of gastric, intestinal, ovarian and febrile 
symptoms would recur and run through their course as before. 
There was, however, no apparent order in their coming, excepting 
that the diuresis came last. 

The remedies that we prescribed jointly did this patient but 
very little permanent good. It was not until the cause of her 

suffering was discovered, or rather until it dis- 
fle^h p " culiar ' lth ° rninthe dosed itself, and was removed, that she got 

well again. This cause proved to be the pres- 
ence of a pestilent old female relative, who gaveihe poor woman 
no peace, upset her domestic affairs, and finally proposed to carry 
off her valuables in the wrong trunk ! 

Having already detailed the proper means of preventing this 
form of sexual irritation, and of its general management, 

it only remains to speak of the remedies that 

may be indicated. Among these the most pro- 
minent is macrotin. In many cases it is an invaluable, and 
indeed an indispensable remedy. Belladonna, atropine, ignatia, 
rhus tox., zincum val., platina, colocynth, china, chamomilla, 
hamamelis, and the lilium tigrinum are equally useful under their 
appropriate indications. 

The symptoms, in the case of Mrs. K., call for ignatia. 
She will therefore take this remedy once in three hours, and 
report. I have no doubt that it will relieve much of her suffering, 
but this does not justify me in claiming that it alone will effect 
a radical cure. 



LECTURE XLVII. 



HYSTERIA. 



Hysteria. Case.— Menstrual disorders in. Case.— Incongruous symptoms of. Malinger- 
ing. Case.— Diagnosis, from cardiac disease. Case.— from asthma, apoplectic 
aphonia, and insanity. Dr. Chairon's pathognomonic sign of. 



Although I have already given you a clinical outline of hysteria, 
the subject is by no means exhausted. Indeed, there is enough 
in this single topic for a whole course of lectures. For this dis- 
order modifies and complicates almost all the diseases to which 
women are liable. 

Case. — At 7 p. M. of yesterday, I was hurriedly summoned to 

the relief of Mrs. , aged 20 years, three months advanced in 

her first pregnancy, who was seized while at the tea-table with 
an unnatural staring and blindness, followed by a species of fit, 
which greatly alarmed the husband and family. I found her lying 
in an unconscious state upon the floor of the dining room. The 
eyes were staring widely and wildly, and at times the eye-balls 
were rolled upwards as far as possible. The pupils appeared nat- 
ural, excepting at intervals of from five to ten minutes, when a 
general spasm of all the muscles of the extremities ensued ; they 
would suddenly increase in size and become very large. With the 
approach of this symptom the face would flush, and she would roll 
from her left to her right side. The arms were thrown wildly 
about, and during the fit it was almost impossible so to hold her 
as to prevent her from doing herself a personal injury. Each 
paroxysm ended with sobbing and an attempt to articulate. The 
pulse was 80 and quite regular. From her manner it appeared 
that she was dreaming and talking, or holding intercourse with 
some person not present in the room, or at least not visible to the 
attendants. While the fit Avas on, the facial muscles twitched 
violently, but there was no frothing at the mouth, or purplish dis- 
coloration of the face. The carmine hue which came and went, 
however, caused her to appear very beautiful. 

T ordered a plentiful supply of fresh air, the clothing to be 
loosened about the throat and waist, and belladonna 3rd to be given 



771 



772 THE DISEASES OF WOMEN. 

her (very slowly) once in twenty minutes until the fits ceased,, 
and after that every half-hour until 1 called again. 

9 P. M. She had only one paroxysm atter taking the first dose 
of the medicine, but the emotional outbreaks had become more 
marked. She would exclaim, "Oh, so dark!" then talk inco- 
herently, and finally cry and sob for some moments most pitifully. 
After a little it became evident through her speech that she was 
in communication with her mother, who, it was said, had died five* 
years before. This last symptom was looked upon as supernatu- 
ral, and alarmed the bystanders exceedingly. They declared it 
to be a premonition, and unfailing sign of the speedy departure of 
the patient for the land of spirits ; but the husband told me that 
she had frequently had similar attacks, and that in all of them she 
had shown this same symptom. 

By my advice she was carried from the sofa to her room, placed 
quietly in bed, the half dozen voluntary nurses discharged, and 
she left alone with her husband for the night. This morning he 
called to report that his wife had slept soundly for some hours, 
and now appeared quite well, although a little weak.* 

Hysterical attacks usually bear some relation to the nnnstrual 
period. A woman is ill with a protracted and debilitating disease, 

as for example pneumonia, or typhoid fever. 
stSafmofimen the men ~ P erna ps she has escaped one or more " periods." 

But the return of the monthly cycle is shown 
in a peculiar aggravation of the coincident nervous symptoms. In 
lieu of the proper flow, she becomes unusually wakeful, restless, 
fitful, or disheartened. Nothing pleases or satisfies her. Her 
nurse is charged with neglect, she thinks that her friends have 
become heartless, or that her physician has lost interest in her 
case. In consequence her family take alarm, and unless he under- 
stands his business very thoroughly, the doctor may be led to make 
an unfavorable prognosis. The perturbation reacts upon the 
patient, who is very impressible, and the hysterical flame grows by 
what it feeds upon. The neighbors clamor for " counsel," or for 
" a change of treatment," and are permitted to have their way. 
The physician who is called in may or may not have tact enough 
to recognize the real condition of the patient. If he can separate 
the hysterical element, can date the exacerbation from the recur- 
rence of the month, can proceed quietly to the cure of the origi- 

* Although similar attacks occurred at the fourth, fifth and sixth months, this patient 
reached term without any further mishap, and was finally delivered of a healthy ten- 
pound child. She had no convulsions in child-bed. 



HYSTERI4. 773 

nal idiopathic disease, all may yet be well. Otherwise she may 
continue to grow worse instead of better. The issue may depend 
entirely upon his skill in diagnosis. The distinctive feature of 
hysteria will sometimes enable you to decide whether those women 
who are ill with acute disease are really in so dangerous a condi- 
tion as they appear to be. 

Although child-bearing, if it be not too frequent or exhaustive, 
is a good general prophylactic of hysteria; and although preg- 
nancy may exempt from an attack of it , 
^Hysteria during gesta- ^\ ie opposite effect may follow conception 
and the arrest of the menses. When, as in 
this case, the disease comes in distinct paroxysms during preg- 
nancy, the fits are more likely to recur at or about the time 
the patient would have menstruated. This fact explains the 
liability of their developing into a form of ante -part um convul- 
sions, of which I have already spoken ; and also the increased 
risk from abortion, which, for physiological reasons, is more immi- 
nent at the month than at other times. 

Attacks of hysteria occurring as a concomitant of other dis- 
eases, or as a contingent of pregnancy and lactation, may safely 
be referred to some emotional excitant. The 

Emotional causes of. . . . 

previous disease, or condition, has caused such 
debility and prostration, as powerfully to predispose to nervous 
derangement, and the patient is an easy prey to the depressing 
emotions. She may be borne down by influences which, under 
different circumstances and at other times would have had little 
or no effect upon her. And these circumstances include a list of 
-avoidable causes which in themselves are so small and apparently 
insignificant as frequently to escape notice. We are very apt to 
forget — if indeed we ever knew — that it is possible for psychical 
causes alone to derange the blood-making process, and to poison 

the very fountain of life. If violent mental 

Possible effects of. . -i-i-i-ip-i-ii 

emotions will prevent the blood ol a healthy 
person from coagulating when it is withdrawn from the body, 
they certainly are capable of destroying life, as by a slow poison, 
when they are brought to bear upon an organism in which the 
blood is already impaired and impoverished to the last degree by 
previous disease. I apprehend that thousands of patients have 
died when otherwise they would surely have recovered, because 



774 THE DISEASES OF WOMEN. 

at a most unfortunate moment they were seized by fear and appre- 
hension, by grief or fright, or jealousy, chagrin, disappointment, 
or some form of mental depression and agitation, from the fatal 
effects of which they could not be rallied. In illustration of this, 
view I may mention the following 

Oasj. — I was called from my hotel at 2 a.m., December 6, 
1861, to visit a most estimable lady who was said to be dying of 
typhoid fever. She had been ill for five weeks under the charge 
of another physician, and had had a morbid fear of death from 
the onset of the fever. The doctor and the counsel had left her 
at 8 p.m., of the previous evening, after having told the family 
that she could not possibly survive the night. My friend, the 
messenger, insisted upon my visiting her and giving her something 
" to make her die easily," as much on his own wife's account and 
that of others in the house, as from motives of humanity. Her 
clergyman had visited her soon after the doctors left, and her 
friends had bidden her a final adieu. She then became apparently 
unconscious, and passed into a peculiar mental state, in which the 
nurse told me she had a vision of her mother, who had died some 
fifteen years before. She then began to exclaim, over and over 
again, " Oh, my blessed mother !" which phrase she had continued 
to repeat so that everyone in the house could hear it. Sometimes 
it was spoken distinctly, and again she mumbled it, so that one 
could not understand what she was sa} T ing ; but it was always in 
the same dreary monotone, which was anything but cheerful in 
the middle of the night, and under such painful circumstances. 

I asked the nurse if the patient could see ? She assured me 
that for several hours she had been entirety blind. Could she 
swallow ? No. Between her exclamations, I thought I detected 
the woman looking at me askant and in a peculiar way. I 
attempted gently to part the eyelids, in order to look at the pupil 
of the eye, but they were so suddenly and decidedly closed as to 
betray a species of volition somewhat inconsistent with the 
alleged danger. The pulse was 115, distinct but excited. I 
called for some water and a spoon. When I separated the lips 
to put a little of the water into her mouth there was a similar 
resistance. The mouth was closed firmly, almost, " with an 
audible snap," as the surgeons say of the sudden reduction of 
certain dislocations. A little tact enabled me to get the water 
into her throat, and to compel her to swallow it. I was impressed 
with the idea that she was really in a semi-conscious state, and 
that some of her symptoms arose from a morbid desire to excite 
sympathy, or, briefly, that they were hysterical. 

A dose of ignatia in the third decimal attenuation was given 
her immediately, and the nurse was directed to give another in 



HYSTERIA. 775 

half an hour, and a third also in case she did not become quiet 
and fall asleep. The room was to be cleared of all the friends 
who had come to witness her death ; she was to be " let alone 
severely," and no one, excepting the nurse, permitted to remain 
with her. The husband and relatives were assured that the dan- 
ger was more imaginary than real, and that if she could sleep and 
be properly nourished, she would almost certainly recover. 

She soon stopped the dreary talk about her mother, became 
calm and fell into a quiet sleep, from which she wakened at short 
intervals. In the morning she was better. She took no other 
medicine, was well fed, and her funeral was " indefinitely post- 
poned." Eleven years have elapsed, and she is still alive. 

Now, gentlemen, you shall decide whether, if some one had 

not recognized the real condition of things in this case, and 

changed it very decidedly, the circumstances 

A practical inference. . tit • 

which surrounded that woman m her weak 
condition, might not have overwhelmed her and caused her 
death. 

The well-known tendency of hysteria to imitate other diseases 
has in it a tinge of deceit. It may simulate almost any affection 

so closely, as to puzzle the best diagnostician, 
hy?t n er1!T tlcal nature ° f and to disappoint the most skillful practitioner. 

Or it may complicate other maladies by coun- 
feiting single symptoms. Women of an hysterical constitution 
seldom pass through the different stages of an acute inflammation, 
or fever, without some peculiar experiences and revelations which 
are totally foreign to the special pathology of the disease in ques- 
tion, These complications may be classed as hysterical. 

In such cases you will observe that those symptoms which are 
incidental and least important, are liable to be incongruous and 

very much exaggerated. If, for example, such 

Suspicious symptoms. , , • ,t t • t • «tt 

a patient has pneumonia, the physical signs will 
not be such as should correspond to her complaints of pain and 
suffering, and to the assumed character of the cough. The sputa 
may tell one story and her tongue another. Or, if she has dysen- 
tery, there may be a similar lack of congruity between the symptoms 
of which she complains, and the visible, objective phenomena. 
Taking the impress of this peculiar idiosyncrasy, or dyscrasia, the 
nervous symptoms, and especially the delirium of such a subject, 
in typhoid, or puerperal fever, will be very greatly modified. In 



776 THE DISEASES OF WOMEN. 

each case the symptoms which are proper to the disease will be 
supplemented by others which are spurious, and also by a more 
or less decided uproar among the physical functions. And thus 
it may happen that your wits will sometimes be taxed to decide 
which is fact and which fiction. The spurious, contingent and 
irrelevant symptoms are the most noisy and clamorous, but not 
most significant and perilous. The complaint that is made is not 
always a reliable criterion of suffering and danger. 

The hysterical subject, whether male or female, is addicted to 

hyperbole. The symptoms of which I have spoken resemble an 

over-anxious witness at court, — they testify to 

Hysterical exaggeration. 

too much. Ihey are actors who " mouth then- 
part.'* This tendency to exaggeration is a suspicious element 
which will bear watching. It is so closely related to the lying 
propensity as almost certainly to betray its true character. You 
will require a large measure of tact and common sense for its 
detection. 

The gossip takes the scent of an ill-assorted marriage, and of 
marital and social infelicities, with the instinct of a hound and 

the tact of a savage. In his diagnosis the 

Incongruous symptoms. .. . 1 , 

doctor is perhaps more easily deceived and 
decoyed. He is generally less shrewd and less skillful in his dis- 
crimination. It may not have occurred to him that symptoms, 
like individuals, are sometimes married without being mated. As 
the fruit of large experience and observation, I am persuaded that 
one great and essential difference between physicians consists in 
their varied ability to separate, to seize upon, to interpret and to 
remedy those symptoms which are truthful, characteristic and 
legitimate, to the exclusion of such as are of secondary import- 
ance, fictitious, accidental and irrelevant. 

There is a species of malingering which is a curious feature in 

some cases of hysteria, a marked example of 

A species of malingering. , . i -, ^ , • 

which came under my own observation some 
years ago. 

Case. — A young lady of sixteen fell ill with the usual symp- 
toms of spinal irritation. She soon complained of a loss of power 
to move the left arm, then the right one, and successively the 
lower limbs also. For eight long years the bed-ridden subject of 
this affliction could neither stand nor feed herself. The sympa- 



HYSTERIA. 777 

thies of the best women oi the neighborhood overflowed in deeds 
of kindness and of charity to the poor sufferer. Finally the nurse 
observed that when she was left alone the patient would some- 
times get possession of articles that were distant from her bed, 
and this without the aid of a third party. By and by a plan was 
arranged to discover if she really did leave her bed in the absence 
of others from her chamber. She was notified that for a short 
time she would be left alone in the house. They watched her, 
and ten minutes after the alleged departure of the family she was 
seen to rise and walk off as well as anybody. The spell was 
broken and she recovered immediately. 

If the consequences of this species of fraud were limited to the 

friends and relatives, who are usually victimized, they would be 

less troublesome and more easily remedied. 

the eC atient ry effects up ° n ^ ut tne worst °f ^ ^ s tnat tne patient may also 
deceive herself. The sympathy and anxiety of 
her friends may cause their judgment to be too easily influenced ; 
and the mental and physical weakness of the patient may finally 
lead her to believe that her symptoms are real, and not assumed, 
as she knew them to be at the beginning. For it is possible that 
a sick person may lie to himself, or herself, and not be able to 
detect it. In hysterics self-deception is frequently compounded 
with the intent to impose upon others. And you will learn from 
experience that it is much easier to correct the impressions of 
those who surround the patient, than it is to dislodge these reflex 
ideas from the mind of the woman herself. 

In diagnosticating the various forms and complications of 

hysteria there are a few signs which almost deserve to be classed 

as pathognomonic. These are (1) that, as a 

Leading characteristics ru i e the disease is limited to females, and in 

oi hysteria. 

them to the period usually termed " menstrual 
life," id est, between the ages of fourteen and forty-five ; (2) that, 
while it may simulate, succeed, or complicate any other disease, 
its symptoms are much exaggerated, irregular, and out of propor- 
tion with those which properly belong to that disease, whatever 
it may be : (3) that, in general, however great the disorder 
among the functions, the pulse is not changed, and the appetite is 
more frequently excessive than deficient. 

Diagnosis. — The cardiac affections with which hysterical dis- 
orders are sometimes confounded are valvular lesions, dropsy, and 
alleged displacement of the heart. 



778 THE DISEASES OF WOMEN. 

When they do exist, the symptoms of valvular disease of the 
heart in hysterical subjects are almost invari- 
theh™n alvular disease ° f abl 7 associated with chloro-anemia. The 
blood is impoverished. The rhythm of the 
heart's action is disturbed, and there is fluttering and precordial 
oppression, palpitation and an exaggerated impulse against the 
thoracic parietes. In chronic cases there may be dropsy of the 
feet and of the face. 

Physical exploration will enable you to decide between real and 
spurious lesions of the valves. In bona fide disease of the valves* 
either the first or the second sound of the heart is impaired in its 
quality, or its place is supplied by an abnormal murmur. If the 
first of these is implicated or superseded, we know that the 
auriculo-ventricular valves are diseased ; if the second sound is 
changed, that the semilunar valves are the seat of the difficult}''. 
In hysterical affections which counterfeit this form of endo-cardial 
lesion both the cardiac sounds are normal. With the first sound of 
the heart, however, we note the soft bellows murmur of anaemia. 

This adventitious sound arises from a change in the quality of 
the blood, as well as from deranged innervation of the heart itself. 
Both sets of valves perform their function properly, and although 
there is palpitation and dyspnoea, yet there is little or no change 
in the pulse. The dropsy of the feet and of the face, f when it 
does exist, are of hemic origin. All the physical signs of valvu- 
lar disease are lacking. There is neither patency nor constriction 
of the orifices, and no insufficiency of the valves that could pos- 
sibly give rise either to obstruction or regurgitation. 

Case. — Miss , aged 22, came to this city from Vermont in 

order to consult me for the relief of precordial symptoms which 
had troubled her for three years. Her disease had been pro- 
nounced a valvular affection of the heart, and she had already 
been treated by three physicians. She complained of languor, 
lassitude, and anorexia, with disgust for meat of all kinds, of 
which she had eaten none for more than two years. The bowek 
were habitually constipated. The slightest exertion caused fatigue 
and a distressing dyspnoea. The recumbent posture was most agree- 
able ; indeed, she could rest in no other. There was almost com- 
plete insomnia. When she did sleep she was not refreshed, but 
awakened with renewed apprehension. The complexion was pale 
and chlorotic, the ale nasi and lips colorless. The pulse 82, weak 
and compressible, but regular. There was occasional palpitation 



HYSTERIA. 77 J 

and painful oppression of the left chest, particularly after exercise 
and when lying with the head low. 

Auscultation revealed the bellows murmur accompanying the 
first sound of the heart, and I felt confident that what had been 
mistaken for organic disease of the valves was really chargeable 
to the deteriorated quality of the blood, She was treated for + he 
ehloro-ansemia, and the cardiac symptoms soon vanished. In three 
months she was quite well, and has continued so during an inter- 
val of six years. 

Women who are supposed to have dropsy of the heart some- 
times complain of great difficulty of breathing after exercise, of 
orthopncea, of cramping, cutting pains in the 

From dropsy of the heart. . . . 

cardiac region, or staling sensations, of a stop- 
page of the heart's action, or of a feeling as if it had suddenly 
turned topsy-turvy, of gurgling, and even as if the heart were 
pulsating in a collection of water. And yet all these symptoms 
may be found to represent a spurious affection. In diagnosticat- 
ing true from false hydropericardium you should remember that, 
in the adult subject, the former is almost always a sequel of rheu- 
matic pericarditis. This is not true of the hysterical disorder, 
which, in its objective symptoms only, resembles dropsy of the 
heart. In real hydropericardium the heart-sounds, the respiratory 
murmur, and the vocal resonance, as well as the pulse, are always 
implicated. The nutritive function is impaired, the blood is thin 
and impoverished, there is a tendency to dropsy of the joints and 
lower extremities, as well as to general anasarca. But in the 
spurious variety the very opposite is true, and no such concomi- 
tants are present. 

JLydropericardium has no necessary specific or setiological rela- 
tion to menstruation and its several disorders. It is a dangerous 
disease, more especially if the patient is of a dropsical diathesis^ 
or if she has had some previous difficulty with the heart, the 
larger blood vessels, or the lungs. Hysterical derangements are 
intimately connected with ovulation, both with respect to their 
commencement at puberty, the recurrence of the attack, the 
aggravation of the symptoms at the "period," the modification 
induced by pregnancy and lactation, and also their cessation at 
the climacteric. They are always more alarming than serious. 

It is not an uncommon occurrence for a hysterical patient to 
complain that her heart is displaced ! And this symptom may 



7$0 THE DISEASES OF WOMEN. 

annoy her exceedingly. The mal-location may appear to her tc 
be either transient or permanent. Emoticna? 
ttehelr? displacement of influences "bring her heart into her mouth.'' 
She suffers from violent palpitation, and some- 
times from abnormal pulsations in different parts of the body; Hei 
general appearance is healthy, her habit is plethoric, and her looks? 
belie her sensations. The anaemic murmur is sometimes so dis- 
tinctly heard by such a patient as to induce the belief that her 
heart is actually dislocated. As a rule you will perhaps encoun- 
ter more numerous cases of this kind among healthy, bouncing 
Irish girls, and the fat, lazy drones of fashionable society than 
elsewhere. I need not tell you that the complaint has no founda- 
tion in fact. ' 

The hysterical cough is a species of nondescript. Its negative 

peculiarities are by far the more prominent. Physical exploration 

will not help you to judge of its cause or sig- 

The hysterical cough. . 

mncance. JNoneoi the symptoms give evidence 
of irritating matters lodging in the respiratory passages, or of any 
lesion of the pulmonary organs. The cough is purely sympathetic, 
reflex in its origin, and serious only through its persistency. 

It is likely to be excited and aggravated by the most trivial cir- 
cumstance, more especially by mental shock and emotional influ- 
ences. In the case of one of my patients the 
slightest movement, the opening or closing of a 
door, however noiselessly, the footstep of an attendant, or the 
least current of air, no matter if she were sleeping, invariably 
precipitated a fit of coughing. There was some tenderness over 
the upper cervical vertebras. She was cured with a few doses of 
silicea 6th. 

Your tact will be called into exercise in order to dispel a set- 
tled conviction that such patients are consumptive. The same 
imitative propensity which sometimes causes a 
toSiTseSeT from pec " number of women to be seized with hysteria in 
a room where another is in a fit, leads those of 
an hysterical constitution to simulate a cough which does not 
depend upon any pectoral lesion whatever, but which may result 
in harmful consequences unless recognized and properly treated. 

This cough is apt to be harsh, dry, barking, and' paroxysmal. 
It alarms those who hear it more than the patient herself. In 



HYSTERIA. 



781 



proportion to the frequency and severity of the paroxysm, the 
affection is sometimes complicated with spasm 
ii^tks pUcations and pecu " °f tne diaphragm, and the singultus annoys the 
patient while it amuses her. This admixture 
of symptoms, especially in the early stages of the disorder, causes 
the proper hysterical symptoms to crop out more prominently. 
She either laughs, sobs, chokes, or cries immoderately. If the 
diaphragm is very much affected, there will be more or less 
orthopncea. The pulse is but slightly, if at all, accelerated, and 
the appetite and digestive function are intact. In case of coinci- 
dent amenorrhea, there may be vicarious menstruation in the 
form of haemoptysis. 

You would diagnosticate the hysterical from other forms of 
asthma by its manifest connection with uterine and menstrual 
disorders. The attack generally precedes the 
monthly crisis and is relieved by it. The tho- 
rax feels tight and restricted. The paroxysm is aggravated by 
emotional causes, more especially by such as excite the passions 
and tend to pervert the moral nature. Even during the suffo- 
cative fit one may sometimes detect the hysterical fondness for 
deception. The regularity of the attack — when it returns every 
month — will confirm the diagnosis. 

The hysterical aphonia is not very difficult of diagnosis. Apho- 
nia is never an idiopathic affection. It may arise from laryngitis 
directly or indirectly, in which case the local 
and constitutional symptoms would aid you in 
making out its differential diagnosis from the hysterical aphonia. 
We may classify the prominent symptoms of the two affections 
thus: 



From asthma. 



Hysterical aphonia 



APHONIA FROM LARYNGITIS. 

1. Febrile disorder ; a quick pulse. 

2. The loss of voice is sudden and com- 
plete in proportion to the extent and 
violence of the inflammation. The 
aphonia disappears slowly, and is 
prone to become chronic. 

3. There is more or less cough "and expec- 
toration, which are paroxysmal, and 
vary in character in different stages of 
the disease. 



HYSTERICAL APHONIA. 

1. Absence of fever ; the pulse is nor- 
mal. 

2. The aphonia comes and goes abruptly, 
and without leaving any local lesion 
or sequel behind it. The relief is 
sudden and perfect. 

3. Cough is a rare concomitant of this 
form of the complaint. There is no 
necessary or characteristic expectora- 
tion. 



782 



THE DISEASES OF WOMEN. 



APHONIA FROM LARYNGITIS. 

4. The inspiration is noisy, harsh and 
stridulous. At an early period it may 
be croupal, but later it is less labored 
and softer. 

5. The dyspnoea is attended by an anx- 
ious expression of countenance. She 
may have fits of suffocation. 

6. There is complaint of angina. The 
fauces and uvula are congested and 
inflamed, with tickling, raw or burn- 
ing sensations, which extend into the 
larynx and trachea. 

7. Pain referred to the pomum Adami. 
These pains are sticking and lanci- 
nating in character. 

8. The anterior surface of the neck is 
sore and tender to the touch, and she 
will not permit one to handle it 
roughly. 

9. In the acute form the aphonia usually 
results from taking cold. 



10. Has no necessary relation to spinal 
irritation. 



In the chronic form it may be due to 
over-fatigue and exeixise of the vocal 
organs, or from causes which occa- 
sion a low grade of inflammation 
with hypertrophy or ulceration of the 
laryngeal mucous membrane. 



HYSTERICAL APHONIA. 

4. The inspiration is heaving, sighing, 
and spasmodic, the idle being moist 
and softened in its tone. 



5. The features are calm and inexpress. 
ive. She is more liable to syncope 
than to suffocation. 

6. There is a complete absence of faucial 
and tracheal inflammation and suffer- 
ing. 



7. There is no complaint in or about the 
larynx. 

8. Globus hystericus, with clutching at 
the throat. She tears away the cloth- 
ing from about the neck. 

9. Never results from this cause unless 
it has first given rise to some men- 
strual or uterine disorder upon which 
the aphonia is secondary. 

ro. Is almost invariably preceded or at- 
tended by symptoms of spinal irrita- 
tation, more especially by tenderness 
upon pressure on some of the cervical 
and dorsal vertebrae. 

:i. When chronic, it invariably depends 
upon some uterine or cerebro-spinal 
lesion. 



You should be careful not to confound the hysterical aphonia 
with the apoplectic. The apoplectic habit, as well as the more 

decided symptoms of cerebral congestion in a 
tic D aphonfl s from apoplec " given case, would remove all sources of fallacy 

in the diagnosis of these two affections. In the 
hysterical aphonia, in addition to the general uproar of the func- 
tions, the result of over excitement, there is an evident hyperses- 
thesia of the brain and spinal cord. In the apoplectic condition 
the loss of voice is a tolerably certain and characteristic symptom 
of congestion of the medulla oblongata. The respiratory ganglia are 
almost certain to suffer from this engorgement, and the organs to 
which the pneumo-gastric nerves are distributed, first the larynx, 
and afterward the heart and lungs, are necessarily implicated in the 



HYSTERIA. 783 

resulting disorder, the causo is centric, and the consequences are 
apt to be disastrous. The hysterical aphonia is always more 
alarming than serious. 

The gastric affections that partake of an hysterical character are 

almost invariably consequent upon uterine luxations or ulceration, 

dysmenorrhea, leucorrhcea, pregnancy, lacta- 

Gastro-hysterical disorders. . .-■,... „,.. 

tion, or spinal irritation. The dyspeptic symp- 
toms are of reflex origin, and differ essentially from those which 
are present in the more ordinary forms of sub-acute gastritis, gas- 
trodynia, gastralgia, etc. In most cases of obstinate digestive 
derangement occurring in women during their menstrual life you 
will observe more or less of the hysterical complication. There 
is the increased suffering at the month, the fickle character of the 
pains, the capricious appetite, the exaggerated complaint of suf- 
fering, and the alternation of the uterine or spinal with the gas- 
trointestinal symptoms. I will speak of this subject more partic- 
ularly at another time. 

Hysteria is frequently confounded with insanity. But the aber- 
ration of the mental faculties in the former affection is almost 

invariably related to disorders of menstruation, 
fromms^nit ^° f hysteria to pregnancy, or to post-partum contingencies. 

Moreover, as in puerperal mania, it is usually 
self-limited, and if not mal-treated, is neither severe in degree nor 
of long duration. In insanity there is evidence of real cerebro- 
mental disease. The reproductive function is not necessarily im- 
plicated, either as cause or effect. The delirium is more lastino-. 
in hysteria the mind is fickle and capricious, the emotions run 
riot, and, as Sydenham long ago observed, the patient " observes 
no mean in anything, and is constant only to inconstancy." 

In insanity there is a manifestation of a strong mental bias. 
There is usually much depression of spirits, which is the result of 
a fixed delusion, of which it is impossible to dispossess the mind 
of the patient. In hysteria a little tact will enable you to recog- 
nize a species of cunning shrewdness that is well calculated to 
deceive. In insanity there is an honest and grave sincerity and 
earnestness that will withstand any amount of analytical cross- 
questioning. A woman with the hysterical form of insanity 
almost invariably dislikes those whom she has hitherto loved the 
best, and towards whom she sustains the most endearing" relation. 



784 THE DISEASES OF WOMEN. 

She may exhibit a decided aversion to her husband, and would 
perhaps even destroy her children. Removal from home, more 
especially if she is not permitted to see her family very frequently, 
will do much toward effecting a cure of her strange and tempo- 
rary hallucination. In case of uncomplicated insanity the victim 
is as prone to suspect and to conceive a dislike for one member of 
the household as for another. 

Hysteria is a paroxysmal disorder, with a great variety of nerv- 
ous and visceral complications, none of which are, strictly speak- 
ing, pathognomonic. Insanity is not regularly paroxysmal,, 
although it may be marked by recurring fits of greater or less 
duration and severity. If we except paralysis, organic nervous 
complications are usually lacking in insanity. Both are hereditary 
disorders, but the predisposition to hysteria is more marked, more 
easily aroused, and more easily acted upon by exciting causes than 
in the case of insanity. In exceptional cases they may co-exist. 

In a very remarkable series of clinical studies upon this disease,. 
Dr. Chairon has advanced some views of its nature which are 
peculiar, and which I can merely reter to at the close of my lec- 
ture.* He insists that its pathognomonic sign is to be found in a 
loss of the reflex sensibility of the epiglottis. '" A.ny woman 
with congestion of one or both ovaries, and having this ansesthesia 
of the epiglottis, has hysteria. ****** At the Im- 
perial Asylum of Vesinet, my internes and myself have tested 
this symptom many hundred times and always with the same 
result. By this sign alone we have often made a diagnosis of 
hysteria, and some days later the fit, or more serious symptoms, 
would confirm our opinion." 

* Etudes cliniques sur L'Hysterie nature, lesions anatomiques, traitement, par le Dr. B. 
Chairon, etc. Paris, 1870. 



LECTURE XLV1II. 

HYSTERIA CONTINUED. 

Hysteria complicating child-bed disorders, fevers, peritonitis, and hypochondriasis. Case. 
— Diagnosis from epilepsy, from peritonitis, from labor, and from lesions of the j int. 
Nature and prognosis. Treatment, there ;1 problem of, mental remedies, imporanceof 
the smallest items in, incompatabidty between the doctor and the patient, narcot cs 
and antispasmodics, alcohol, proper exercise, domestic o cupation and contentment. 

The hysterical delirium is in many respects peculiar. It is liable 

to occur in typhoid, typhus, the eruptive and puerperal fevers, and 

also in certain menstrual and hepatic disorders. 

Hysterical delirium. . 

In a case either 01 typhoid or typhus fever, 
occurring in a young or middle-aged woman, if the delirium per- 
sists after the more acute symptoms have subsided, and especially 
if there is no particular evidence of cerebral lesion , if the parox- 
ysms thereof return at irregular intervals, and result from trivial 
causes, which in one who was seriously ill would have little effect ; 
if the mind is more than usually fitful and capricious, or if it be 
inclined to dwell upon a single train of ideas, which have grown 
out of the most ridiculous fancies , if these vagaries are outre and 
otherwise inexplicable , you will be led to suspect the hysterical 
complication. And your suspicion would be confirmed by any 
evidence of malingering on the part of the patient. 

She will not look one directly in the face. Her eye is averted, 
cast down and expressionless, like that of a young man with sper- 
matorrhoea which has been brought on by self- 

The patient's manner. 

abuse. Or it has a roguish look, and twinkles 
with evident satisfaction at the alarm and discomfiture of the 
bystanders, upon whose sympathies she may have been playing as 
upon a harp. During the fit, in assumed fear of dysphagia, or 
from a settled determination that nothing shall pass her lips, she 
may peremptorily refuse to swallow either food or medicine. 

She is sensitive, impressible, tearful. Her perceptive faculties 
are intensified. She sees and hears every motion that is made in 
the house. Nothing escapes her. For her to remain passive is an 
impossibility. She is under the dominion of an evil genius, which 
destroys her own peace and that of all concerned. 

50 ib& 



786 THE DISEASES OF WOMEN. 

This form of delirium is likely to be caused or aggravated by 

the taking of drugs to blunt the sensibilities and to compel the 

patient to rest and sleep. Any of the narcotics 

Aggravated by drugs . n 

may in exceptional cases produce an opposite 
effect from that which was intended. Under these circumstances 
they increase the perturbation and unhinge the nervous sympa- 
thies more and more. Even when the patient is easily narcotized, 
it is doubtless true that the habit of taking such remedies as the 
bromide of potassium or the hydrate of chloral, in increasing 
quantities, may finally work serious mischief. 

During the convalescence of fevers, the hysterical delirium may 
be suddenly developed in consequence of an incidental derange- 
ment of the menstrual process. The same is 

Incident to fevers. pi • • 

true 01 a tardy resumption ol the ovarian and 
uterine functions after delivery or prolonged lactation. Until the 
organic processes have resumed their natural order, and the period- 
ical discharge appears, there is danger, especially after acute 
disease, of the mental functions becoming temporarily impaired. 

The hysterical delirium is often present in child-bed fever, how- 
ever mild its type. In this case it arises from reflex causes, and 

we very naturally refer the symptoms to some 

In child-bed fever. . . . _ . 

remote lesion ot the soit parts withm the pelvis. 
This delirium varies in its intensity with the quantity and quality 
of the lochia and of the lacteal secretion, being less marked and 
persistent if these post-partum products are fieely and uninter- 
ruptedly poured out. It also varies with the gravity of the uter- 
ine lesion. Even in the most aggravated cases of delirium and 
puerperal mania, it is quite absurd to speak of a metastasis of 
uterine phlebitis, or of utero-peritoneal inflammation to the brain. 
In rare cases the hysterical delirium is complicated with a form 
of hypochondriasis that results from some chronic hepatic disor- 
der. If uterine lesions are conjoined with an 
May be complicated with i c i organic disease of the liver, and the patient 

hypochondriasis. o J- 

has delirium, that delirium is necessarily of 
serious import. Hepatic abscess may co-exist with uterine dis- 
placement, ulceration, or enlargement, and a form of delirium 
exist which is both hysterical and hypochondriacal. In such a 
case the danger is increased by the resorption into the blood of at 
least one of the post-organic elements of the bile, viz. : the cho— 
lesterine. 



HYSTERIA. 787 

It is less difficult to separate hysteria from hypochondriasis than 
from the more decided forms of insanity. In hysteria the mental 
derangement is not always, or indeed usually, 
h^o^ O nd S n ? a f sb ysteriafr0m °^ a desponding or gloomy kind. The attack 
comes on suddenly and without warning ; is 
explosive in its nature. The classes of persons predisposed to the 
two diseases are of very different habits of thought and tempera- 
ment. Those most liable to hysteria are the fitful and the frivo- 
lous, such as have not taken especial pains in the culture of the 
reflective faculties. Hysteria is limited almost exclusively to 
women. A majority of cases of hypochondriasis occur in men. 
Aristotle observed that " melancholy men are the men of the 
.greatest genius." Hysteria affects the perceptive, hypochondriasis 
the reflective faculties of the mind. In the former it is intact and 
the perceptions are morbidly acute. In the latter the gloomy 
forebodings, the delusional insanity, impair all the mental pro- 
cesses ; the perceptions are misinterpreted, and the judgment is 
perverted. When hysterical females become hypochondriacal, 
their thoughts almost alwaj^s take a religious turn, and the delu- 
sion develops into a mild form of theomania. 

I was recently consulted in a case of this kind by my friend and 
former pupil, Dr. C. N. Dorion, of this city, from whom I have 
the following details concerning his patient : 

Mrs. M , 25 years of age, was married two years ago, but 

has no children. Her complexion is sallow, 
the menses are regular, but, for the last four or 
five months, rather scanty. The appetite is variable, the bowels 
are somewhat constipated. She suffers no pain excepting an 
occasional attack of headache which is not very severe. Her con- 
stitution appears to be good. Her face wears a melancholy 
expression. Her father is subject to fits of hypochondriasis, and 
one of her sisters has been insane for several months. 

Last summer she made a visit to that sister, and spent some 
days with her in the insane asylum. Since that visit she has been 
very much afraid of becoming insane herself, and has a mortal 
dread of dying in a mad -house. She is in terror of being left 
alone. When her husband leaves home in the morning, she feels 
sure that she will never see him again. Her mind runs constantly 
upon religious topics, and she will sit and sing hymns for hours 
together. She has lost all interest in domestic affairs, and the 
outside world is a complete blank to her. 



788 THE DISEASES OF WOMEN. 

When lying down she fancies that it will be quite impossible 
for her ever to rise again, or to walk if she were upon her feet. 
She thinks and says that she is too weak to do anything. Occa- 
sionally there are nervous shiverings, globus hystericus, cold 
extremities, and, at rare intervals, an intermittent pulse. The 
tongue is coated white, but there is no febrile action. She broods 
over her certain death, her possible insanity, her sins always. 
When one succeeds in diverting her attention temporarily, she is. 
apparently quite well and says that she is no longer sick. But in 
a short time she lapses again into the same pitiable state of mind 
as before. She insists that for weeks past she has not been able 
to sleep, even for a single hour. 

Among the hysterical contingencies and sequelse of labor none 
are more embarrassing than those which simulate puerperal peri- 
tonitis. Post-partum hysteria is sometimes 
The hysterical form of very clifficixlt of recognition. We most natur- 

pentonitis. J © 

ally look for it in those who in the unimpreg- 
nated state have been subject to mental unsteadiness, and who 
through original or acquired predisposition are considered to be 
"nervous." The changes incident to gestation frequently have 
the effect to fortify against an hysterical outbreak until " term " 
has arrived. But either during or subsequent to delivery the old. 
habit is revived, and symptoms of hysteria may crop out again. 

In this spurious form of peritonitis the attack comes on ab- 
ruptly and without any obvious cause. It may even be entirely 

emotional in its origin. Everything may be 

Differential diagnosis of. . ° . -. , 

natural with the . lying-in woman when a slight 
mental shock has the effect to make her alarmingly ill. There is 
local pain and tenderness over the abdomen. She can not bear 
slight pressure, the weight of the bed clothing is unsupportable, 
the lower extremities are sometimes but not always flexed, the 
abdomen is tympanitic, the urine is either scanty or suppressed. 
The skin is neither unnaturally hot nor cool. She has no decided 
chill, but may ha\?e rigors. The pulse is nearly or quite natural. 
If at all changed it will usually be found slower than at your last 
visit. The delirium is hysterical. If, for example, you attempt 
to administer a remedy in the form of a little powder, she will 
seize it and tear the paper to pieces in a twinkling. And this 
most deliberately and defiantly, perhaps. She clenches her teeth, 
closes her lips, thrusts her face into the pillow, tosses about from 



HYSTERIA. 781) 

side to side, or persists in sitting up, even although she may be so 
sleepy as scarcely to be able to keep her eyes open. 

Now, in genuine child-bed fever, although there is no pathog- 
nomonic lesion, any more than in surgical fever, to which it is 
closely allied, the symptoms differ essentially from those which I 
have just enumerated. If there is perimetritis, endometritis, peri- 
tonitis (ovarian or abdominal), or metro-phlebitis, the usual con- 
stitutional signs of local inflammation will be present. 

Thus, in true puerperal peritonitis, we shall have a characteris- 
tic frequency of the pulse, which continues despite a copious 
diuresis or diaphoresis ; a decided chill at the onset of the attack, 
as in inflammation of serous membranes elsewhere ; severe frontal 
headache ; a suppression of the milk and of the lochia • excessive 
abdominal distension and tenderness, which latter is greatly in- 
creased by extending the limbs or allowing the clothing to fall 
upon the tumor ; and a hippocratic expression of the countenance. 
In the worst cases the period of collapse sets in early, and the 
patient may die in a very few days, or she may linger for a week 
or more. 

In private practice puerperal peritonitis is a rare affection. 
Probably not one-half the cases of this disease that are reported 
in our medical societies and journals deserve to 
be classed as such. The clinical history of such 
oases proves many of them to have been spurious, self-limited, 
incidental, hysterical. Any remedy capable of controlling the 
nervous symptoms, which are contingent upon labor, is very 
likely to get the credit of aborting a genuine attack of peritonitis. 
The same is true -of the hysterical side-ache which resembles 
pleurisy and is so often mistaken for it ; and also of the hysteri- 
cal pains which sometimes counterfeit rheumatism so closely. 
When you hear a physician say that he has often succeeded in 
curing any one of these diseases — peritonitis, pleurisy or rheu- 
matism, in a few. hours with this or that remedy, you may safely 
conclude that his clinical observations have not been very accu- 
rate, and that he is claiming too much for his skill. 

There is a singular and significant relation between abdominal 
tympanites and the mental derangements, more particularly the 
forms of delirium, to which hysterical women are liable. It 
frequently happens that the degree of abdominal distension is 



790 THE DISEASES OF WOMEN. 

a measure of the temporary disorder of the brain. Whether this 

tumefaction of the abdomen, and sometimes of 

Abdominal tympanites £] ie hvposrastrium also, is to be regarded in the 

and delirium. J L o o 

light of cause or effect, authorities are not agreed. 
It is incident to difficult and delayed menstruation, to the puer- 
peral state, to abortion, to uterine displacements, and to the vari- 
ous forms of sexual irritation from whatever cause. It is some- 
times brought on by mental shock or emotional influences of 
different kinds, as fear, anger, grief or disappointment. You will 
find in these cases that the abdomen is excessively tender to a 
slight touch, but not to steady and continued pressure. This dis- 
tension may come on very quickly and disappear as suddenly, 
without being accompanied or followed by any local inflamma- 
tion. I have known it to be caused by drinking a glass of ice- 
water, or eating a dish of ice-cream, during menstruation. In a 
few minutes after taking the latter the abdomen was found to be 
enormously swollen and the patient delirious. Similar states of 
the mind are incident to the tympanites intestinalis of puerperal 
and typhoid fevers. But, in many cases of hysterical tympanites, 
which are really due to derangement of function in the solar 
plexus and semilunar ganglion chiefly, you will observe that con- 
tinued pressure upon the stomach and abdomen, when 'the pa- 
tient's attention is diverted, will not only arrest the unnatural 
secretion of gas, but will cause both the swelling and the delirium 
to subside. This is sometimes quite diagnostic. 
„ . Hvsteria mav simulate natural labor. A marked 

Hysteria may counter- «/ ^ 

feitlabor - case of this kind is reported by Dr. Hodges.* 

tw I was engaged to attend a married woman in her confinement 
for the first time, then believed by herself and friends to be about 
five months advanced in pregnancy. Time went 
on — the usual preparations were made — the 
nurse secured, the patient happy in the thought of becoming a 
mother, and pleased with the sympathy elicited from the neigh- 
bors in relation to the approaching event. In four months after 
the first intimation I received, I was requested, at about ten o'clock 
at night, to visit her, and to do so with as little delay as possible, 
for she had been ill all clay, and was reported to be getting rap- 
idly worse. On arriving, the pains were very severe, and of the- 
kind attending the last stage of labor. I was pleased to hear 
from the nurse that the pains had been very regular all the day,, 

* Trans, of the Obstetrical Society of London, Vol. I, p. 339. 



HYSTEKIA. 791 

gradually increasing in frequency and intensity, for the hope of a 
night's rest was before me. They certainly were most severe and 
forcing, and succeeded each other so rapidly as to give the impres- 
sion that the process would soon be completed, and the first casual 
vaginal examination conveyed to my mind the same idea, for I 
detected a soft, fluctuating tumor, filling the vagina, and which, 
during pain, distended and protruded it through the os externum, 
precisely as in natural labor when the membranes protrude. I 
made no observation to those around me, for the pains were so 
urgent and forcing that I believed the labor would be over in a 
minute or two ; but their continued severity brought no advance- 
ment — no alteration. I then examined carefully into the cause 
of this apparent delay, and found that the tumor was a vaginal 
cystocele, or prolapse of the anterior parietes of the vagina, 
caused by an enormously distended bladder. The finger was 
with difficulty passed up behind this swelling, where the uterus 
was discovered with its mouth closed and of the unimpregnated 
size. The patient and attendants were then informed that, not 
only were these pains spurious, or false, or hysterical, * * * 
but that the patient herself was not even pregnant, which fact 
astonished them still more, and amused them for many a day. 
* * * The patient before marriage was subject to frequent 
attacks of hysteria, and about one year previous to this event was 
present at a relative's accouchement, where the pains were severe 
and the labor protracted/' 

Hysteria and epilepsy are frequently confounded by those who 
pay too little attention to diagnosis. The points of difference 
between them concern the coming on of the 
from ia fpn?p S y f hysteria paroxysm, the symptoms during the fit, and 
those which immediately follow it. In epilepsy 
there is usually some premonition of the spasm ; the patient may 
fall to the floor, or the fit may come on immediately upon awaking 
out of sleep ; the aura epileptica is more or less pronounced ; the 
attack is not strictly referable to an emotional cause, but is apt 
to be periodical, occurring once in so many hours or days ; it has 
no necessary relation to menstrual disorders, to the return of the 
month, or to enfeebled conditions of system consequent upon ges- 
tation or lactation. The hysterical fit follows some mental shock 
or strain ; comes on oTaduallv, usually with more or less of gastric 
disturbance and distress, choking, suffocation, globus hystericus, 
twitching and convulsive movements of the eyeballs and the eye- 
lids ; is very apt to follow in consequence of loss of sleep ; and if 



792 THE DISEASES OF WOMEN. 

at all periodical, it is more likely to recur at the month as a con- 
tingent of menstruation. In certain cases pregnancy and lacta- 
tion may predispose to it most decidedly. 

In the epileptic fit there is a sudden and total loss of conscious- 
ness. The face becomes livid and distorted ; a frothy saliva flows 
from the mouth, and there is grinding of the teeth and biting of 
the tongue. The patient is entirely oblivious to all that is pass- 
ing. The convulsive movements affect the muscles of the face, 
neck, throat, chest and extremities. The larynx is spasmodical!) 
closed, and hence the discoloration of the skin, and the temporary 
arrest of breathing. When the spasms reach the muscles of the 
extremities, those on one side of the body are apt to be more 
decidedly affected than those on the other. These spasms are 
more tonic than clonic. The movements of the patient are 
entirely involuntary. 

In the hysterical paroxysm, if the patient becomes comatose 
(which is exceptional), this condition comes on very gradually 
and may not be complete until at the close of the fit. The face 
ma} r be flushed, but it is not dusky or livid in hue ; she does not 
foam at the mouth ; as there are no convulsive movements of the 
lower jaw, the tongue is not apt to be bitten ; and, what is quite 
distinctive, she displays something of volition in all her move- 
ments, and evidently "keeps the run' 1 of what is going on around 
her. She sighs, or laughs, or sobs, or perhaps talks as if dream- 
ing. The muscles of the face are seldom convulsed ; the face 
itself is not disfigured ; the larynx, which is the gateway of the 
respiratory system, remains open ; and the movements of the 
extremities are always partly under control of the will. 

The epileptic paroxysm is generally of short duration and 
passes off with profound sleep, from which the patient awakens 
without the remotest idea of what has passed since the onset of 
the attack. Whether sleep follows the fit or not, 'there is con- 
siderable dullness and hebetude of mind which may continue for 
hours or days, and which finally, if the fits recur very often, 
impair the intellect and render the patient a complete wreck. 

The hysterical coma may become more profound and the patient 
may sleep toward the close of the paroxysm, but the rule is that 
the fit passes off with an ebullition of emotional feeling. She 
may either weep or laugh immoderately. Or she may sigh and 



HYSTERIA. 793 

groan and sob, and all this without any real mental anguish to 
correspond with these demonstrations. Her emotions run riot, 
and are sometimes most grotesquely jumbled together. She may 
know more of what has passed since the commencement of the 
attack than the bystanders themselves, and the only perceptible 
effect of a repetition of these paroxysms seems to be so to shatter 
her nervous system as to make her more and more susceptible to 
them. In many cases the fit terminates with a copious flow of 
pale, limpid urine. 

You will hardly fail to be consulted for the relief of certain 
liysterico-neuralgic affections of the spine. These affections are 

very distressing because of their chronic na- 
irrhldo^ ° r " spinal ture, their proneness to seize upon some of the 

most intelligent, gifted and amiable women in 
society, and because it almost always happens that before you are 
applied to, they will have done the very thing, and resorted to 
the very means best fitted to fasten the disease upon them. In 
these patients some portion of the spine — it may be a spot over 
the spinous process of a single vertebra, or perhaps the whole 
length of the column — becomes exquisitely sensitive to the touch. 
The pain may be sharp or dull, radiating, shooting, shifting, tran- 
sient or permanent, and is very apt to be increased by over-fatigue 
of body or mind, vicissitudes of weather, as of cold and damp, 
strong mental emotions, sleeplessness, obstinate constipation, and 
the return of the menstrual crisis. It renders walking impossible 
in many cases, and may even interfere with riding also. The inci- 
dental symptoms vary with the seat of the local pain, but are not 
as serious as you would be led to infer. Indeed, the exaggerated 
character of the complaints that are made will prevent your con- 
founding this with caries of the vertebras, or with myelitis or spinal 
meningitis. The predisposition to this disease is the hysterical dia- 
thesis ; the exciting cause may generally be found in some derange- 
ment of the menstrual function upon which the " spinal irritation " 
is secondary. Such patients sometimes suffer extremely from neu- 
Talgia in various parts of the body Exercise gives them so much 
pain and unrest that they soon desist from taking it, and finally 
become bed-ridden and wretched. 

Sometimes this peculiar disease locates itself in one of the larger 
joints, particularly in the hip or the knee. Dr. Simpson reports a 



791 THE DISEASES OF WOMEN. 

case in which the pain was seated in the head of the right radius- 
The knee-joint is most frequently affected- 
thStf laffections ° f There is the greatest dread of motion of the 
affected part, and the pain is said to be excru- 
ciating in degree, much more, indeed, than in case of real ulcera- 
tion of the cartilages. This affection, which is comparatively 
frequent, was first described by Sir Benjamin 

Diagnosis of. ' .'.'•.. • 

Brodie, who says, concerning its diagnosis, that 
" There is always exceeding tenderness, connected with which, 
however, we may observe the remarkable circumstance, that 
gently touching or pinching the integuments in such a way as 
that the pressure can not affect the deep-seated parts, will often 
be productive of much more pain than the handling of the limb in 
a rude and careless way." A good plan is to divert the patient's 
attention from herself while you are manipulating the affected 
part, by which means you will find it possible to move the joint 
with little comparative complaint from her. If she insists that 
the limb can not be moved or straightened voluntarily, you ma}~ 
resort to anaesthesia by ether or chloroform as a means of making 
a more careful diagnosis ; for it is really very important to decide 
in these cases whether the disease is or is not hysterical. It has 
frequently happened that women have been kept in bed, in the 
horizontal posture, for weeks and months, and even for years, 
when there was no actual disease of the joint itself. Indeed they 
have often gone through the martyrdom of blistering, cupping, 
leeching, salivation, and finally of amputation, for the cure of this 
reflex disorder. 

If you remember the distinctive characteristics of hysteria that 
have already been enumerated, you will be spared the commis- 
sion of such blunders, and your patients saved from the prolonged 
suffering which, as a rule, may be easily remedied. 

In the unmarried, and sometimes in women who are married but 

who have not borne children, vaginismus is an attendant upon 

hysteria. In exceptional cases the hysterical 

Other incidental diseases. _. - ' 

disorder appears under the iorm ot nymphoma- 
nia. Numerous instances are recorded in which ovariotomy has 
been attempted, when on opening the cavity of the abdomen the 
tumor has proved to be an hysterical phantom. 

Nature. — But it must suffice to say that hysteria is rather a 



HYSTEEIA. 795 

condition than a disease per se. This condition appears to consist 
in a peculiar irritability and impressibility of the 
dis^Js S e terian ° ta ^^' /f ^ nervous system, which is so modified by disor- 
ders of the sexual apparatus as to cause it to 
differ from every other kind of nervous derangement. This mor- 
bid irritability should be regarded in the light of a peculiar dia- 
thesis, upon which, as we have seen, almost any disease may be 
engrafted. Roberton says very explicitly : * " We have reason to 
believe that there is as absolutely an hysteric constitution, or con- 
genital predisposition to hysteria, as that there is a scrofulous con- 
stitution, or congenital predisposition to scrofula ; and conse- 
quently that none are liable to hysteria but only such as possess 
this constitution. 

" The hysteric condition is characterized by irritability, sui gen- 
eris, of the nervous system as a whole, or sometimes more partic- 
ularly as connected with certain organs ; and although this condi- 
tion can not probably be originated in the individual by modes of 
living, and other external circumstances, it may be aggravated by 
them." 

In what this hysterical predisposition really consists we do not 

know. How it is that it reverses the finer traits and characteristics 

of womanhood, whether temporarily or perma- 

Its real nature is unknown. ,,.,.. ., , , -. — ,, 

nently, it is impossible to comprehend, I hat 
such are among its effects is a thing of every-day observation. It 
is at the bottom of half the disease and the unhappiness of the 
sex. It may turn the wife against her husband, the sister against 
her brother, the daughter against her father, the mother against 
her child, and friend against friend the world over. Its strange 
characters may be traced upon every page of human history. In 
the affairs of church and of state, in medicine and morals, in soci- 
ety at large and in the sick-chamber, its influence is certain to be 
felt. It does not destroy life directly, but indirectly it has slain its 
thousands. In brief, it is the most mischievous and the most 
enigmatical and elusive of all those elements which enter into the 
formation of " poor, weak, human nature." 

Prognosis. — Uncomplicated hysteria is not a fatal disorder. It 
may, however, serve to conceal the graver symptoms of disease 

* Essays and Notes on the Physiology and Diseases of Women. London, 1851. 
P- 237. 



79() THE DISEASES OF WOMEN. 

under cover of such as are not serious, and in this manner tends 

to destroy life by causing the real lesion to be overlooked. Let 

me illustrate : A delicate, nervous woman is 

Illustration. . 

seized with a sharp attack of pleuro-pneumonia. 
In the emergency of her sudden illness an officious neighbor is 
called in. This impromptu nurse has a voice and manner that 
serve only to excite the patient more and more, and, despite her 
bundle of expedients, some of which, if properly applied, might 
have been efficacious, the symptoms are aggravated. The reflex 
effect of that woman's presence and performances upon the sen- 
sibilities of such a subject is so to shock and derange them, that 
it may be quite impossible for the doctor when he arrives, to discrim- 
inate properly between the symptoms that are presented. He 
can not tell which of them are genuine and which are spurious, 
for the former are masked, while the latter are lashed into undue 
prominence. All the symptoms that are chargeable to the nurse's 
lack of tact, to her incompatibility and to surrounding circum- 
stances generally, rather than to internal conditions of the patient's 
organism, will be likely to deceive and mislead the physician. 
Vesical or rectal tenesmus, globus or clavus hystericus, fugitive 
and excruciating local pains and spasms, a temporary diabetes in- 
sipidus, aphonia, hysterical vomiting, amenorrhcea, or a host of 
other irrelevant symptoms, not one of which has any characteristic 
relation to the original disease, are so magnified, and stand out so 
olearly and prominently, as to divert his mind into the wrong 
channel. 

Under these circumstances, and especially if he is inexperienced, 
the physician may feel himself called to prognosticate a fatal issue. 
Taking the wrong cue, adding to the alarm instead of arresting 
it, and causing matters to become worse in compound ratio — for 
doctors are either helpful or harmful — the patient may finally die, 
not indeed of hysteria, but of the pneumonia which has been per- 
mitted to run its course without interruption, because it has been 
overlooked. 

Or, if the physician in charge has had sufficient experience, and 
has tact enough to enable him to recognize the hysterical out- 
growth in such a case, but is withal very much occupied, and 
weary with this class of patients especially, he may hastily con- 
clude that she has a fit of hysteria and prescribe accordingly. 



HYSTERIA. 79? 

Meanwhile the real disease is making rapid progress, and before 
his next visit it may have become incurable. 

Now it is this deceptive exaggeration that is likely to mislead, 
and to cause us to misjudge, to overrate, or to underrate the dan- 
ger in cases of hysteria complicated with other forms of disease. 
Some of the verbal and objective signs are untruthful. They in- 
troduce the lying element into the record, and hence the difficulty 
in detecting them and in assigning their proper diagnostic and 
prognostic value. 

Treatment.— Before we proceed to the special therapeutics of 
this affection, there are some considerations 

General remarks. . . n . 

which, demand our notice, and which are essen- 
tial to its proper and successful treatment. 

This disorder being chiefly emotional in its origin, and indeed 
in its very nature, it is vitally important to obtain such an in- 
fluence over the mind of the patient as will 

Mental remedies. 

serve in a measure to control the symptoms, or 
at least to place her in a state in which our remedies will act 
more promptly and efficiently. There can be no doubt that very 
many cases of hysteria, in some of its protean forms, have been 
unwittingly cured by means that were suited to occupy, divert, 
overwhelm, or control the emotional faculties. Such expedients 
are to be regarded only as auxiliaries to proper treatment, but as 
such they are so useful, and sometimes so necessary, that they 
should not be overlooked. For it has often happened that the 
manner and bearing of the nurse, or of some kind-hearted neigh- 
bor who has been called in, has done a thousand times more to 
cure these patients than the physician's prescription. The intan- 
gible, but no less potent influences of fear, faith, hope, confidence, 
will, reason, diversion, management, occupation of the mind, ar- 
gument, concession, opposition, sympathy, indulgence of caprice, 
helping her to bear her burdens— whether real or imaginary — 
change of diet, air and scenery, are sometimes indispensable. And 
unless we can use them appropriately, or the patient shall happen 
to be accidentally brought under their influence, the best chosen 
remedies will utterly fail of effect. 

Herein lies the difficulty in controlling and curing the various 
forms of hysteria. The most inexperienced among you might 
match a great many of the symptoms mechanically, and prescribe 



798 THE DISEASES OF WOMEN. 

for them secundum artem. But, unless you are able to recognize 
which of them are genuine and which are 

The real problem. 

not ; unless you can separate the real from the 
spurious ; unless you can refer those which are hysterical to their 
proper source, and succeed in reducing the emotional disturbance 
of the patient to order, you will fail to cure this disease. 

Now, there are many ways of accomplishing this object. You 
know that hysterical patients are eccentric. For this reason it 
requires a large measure of tact (which can only be acquired 
through observation and experience) to manage them properly, 
and to cure them most certainly and promptly. I can no more 
tell you what to do in each particular case of hysteria than I 
could define the odor of small-pox or of measles. But it is pos- 
sible to give you some general directions that shall be useful. 

In the first place, if you desire to be most successful in treating 
this class of diseases, you should maintain your distinctive char- 
acter as physicians. For there is a species of 
therc^'s\ibk e s ndsupon mutual reserve and respect which should sepa- 
rate the physician from his patients, and which 
invest him with a peculiar influence over them. If this is prop- 
erly maintained, it need not subtract from the social character 
and position upon which so much of his general reputation de- 
pends. But it will give him an immense advantage in the man- 
agement of every kind of hysterical disorder, to which so many 
of his lady patients are subject. 

Nor is a highly-wrought, delicate, impressible, nervous woman 
likely to be benefited by the advice of a physician whose personal 
habits and manners are repulsive to her, and 
dreVs S ,°etc! s pers ° nal ad ~ whom she is compelled to tolerate rather than 
esteem. In this, as in other matters, trifles 
have great weight. I have known a brother practitioner, who 
was skillful and competent, to be discharged by such a patient 
for the reason that " he never wore a decent cravat." His slovenly 
habit more than counterbalanced the effect of his remedies, and, 
while he continued to visit her, his patient grew worse instead of 
better. The good influence of one physician may be crippled by 
his loquacity, another is too taciturn ; a third asks too many, and 
a fourth too few questions of the patient ; one brings too full a 
budget of news from a neighbor ; another is eternally canvassing 



HYSTERIA. 799 

for his school of medical practice, his church, his club, or his 
political party ; one is too cross, while it is alleged that another is 
•*' altogether too kind." 

This is but a scanty list of personalities, any one of which may 
serve, in this class of diseases especially, to neutralize the curative 

effect of his remedies. You are not to suppose 
always trivial ltemb not that they are insignificant merely because they 

are not alluded to in your text-books. What- 
ever can by any possibility constitute an obstacle to recovery is 
important and worthy of your attention. Fortunately most of 
these vexations are avoidable. You will not all excel in obtain- 
ing the confidence of your patients, and in bringing them into 
that passive state in which they can be most readily cured. But 
each of you can by education acquire such a measure of tact and 
of adaptation to caprice and circumstance as will multiply your 
resources and render you many times more useful to them. 

I am so confident that a lack of sympathy, a dearth of feeling, 
a real incompatibility of temper and taste between the physician 

and his hysterical patient may cause his treat- 

Incompatibility between -i , n -i ,t j? i 

physician and patient. me lit to result in m ore ot harm than oi good, 
that, iii case this obstacle can not be otherwise 
removed, I think it better to withdraw and to let another phy- 
sician be called. Indeed, I have sometimes voluntarily discharged 
myself, after having frankly told the patient and her family that, 
for some unknown reason, my remedies had 

How to remedy it. . 

failed to cure her ; and that, m my judgment, 
such a change was what she most needed. Under similar circum- 
stances we would not hesitate to discharge the nurse whose every 
movement was annoying to the patient and antagonistic to her 
comfort and welfare. And I do not knoAV why the same rule 
should not also apply to the doctor. If a new face and a new 
method of prescription will work the desired change in her feel- 
ings and her symptoms, by all means let them be tried. For these 
things can operate through the emotions, and may entirely super- 
sede the necessity for remedies of whatever kind. And by fol- 
lowing this rule, although you lose the credit of curing one such 
patient, you will gain the reputation of saving another ; for, when 
the wheel turns around, your face and your manner may be the 



800 THE DISEASES OF WOMEN. 

one thing needful in a similar case which your professional neigh- 
bor has failed to relieve, 

In lieu of controlling the emotional outbreaks and suffering in 
hysteria, by the personal tact, character and magnetism of which 
I have spoken, these subjects are often brought 
mS?cs° tics and Anti " spas " under the quieting influence of narcotics and 
anti-spasmodics of various kinds. But such 
medicines are mischievous, and should be given under protest and 
exceptionally, or rather not at all. One reason why there are so 
many nervous women in our clay is, that the habit of taking such 
drugs is almost universal. And every few months a new one is 
added to the list. Thousands of women, who should be well and 
healthy, are just now under the slavish domin- 
ion of the hydrate of chloral and the bromide 
of potassium. The taking of these substances habitually begets 
a predisposition to nervous disorders which grows apace. So that 
if there were no other reason for withholding them from our 
prescriptions, we should not give them freely and indiscriminately, 
lest the habit be formed in consequence. 

There are, however, exceptional cases in which this means of 

temporary relief can not be rationally excluded.- When from 

excess of pain, fatigue, or excitement, it is ab- 

Sometimes permissible. 

solutely impossible otherwise to procure the 
needful rest, they are perhaps permissible. But these are excep- 
tional cases in which we must choose between two evils. It may 
be better to compel sleep, to overwhelm the nervous centers, and 
to run the risk of the secondary consequences of such an expedi- 
ent, rather than let the patient wear herself out with unrest, 
extreme pain, or protracted insomnia. 

Concerning the propriety and advisability of alcoholic stimula- 
tion in the weakened conditions of the nervous system, which 

predispose to, and attend upon hysterical dis- 

Alcoholic stimulation. . . _ 

orders, physicians are not agreed. One class, 
of which Dr. Skey is the modern representative,* considers them 
indispensable, and insists that they should be given freely and 
promiscuously. On the contrary, what might be called the de- 
nunciatory school is equally positive that in all forms alcohol is 
always injurious. 

* Skey on Hysteria. A. Simpson & Co., N. Y., 1867. 



HYSTERIA. 801 

This involves a question which can not be settled for you in 
the lecture-room. If you are satisfied that these agents can be 
utilized in correcting the mal-nutrition and depraved vitality 
from which this class of patients often suffers preeminently, it 
will be your duty to prescribe their sparing and transient use. If 
you need to husband the vital resources of one who is exceedingly 
weak, and almost bankrupt in strength, and are satisfied that 
alcohol, or tea, or coffee will diminish disassimilation, and prove 
a veritable 4w savings bank to the tissues,' ' as Moleschott so 
quaintly terms it, you should not withhold them. 

Under certain circumstances it may be quite as necessary to 

furnish a rapidly oxydizable material to the organism, as in other 

conditions it is to supply oxygen itself. I might 

Folly of dogmatizing. . . _ . iX " -,-1 1 

insist that wine, brandy or whiskey nave never 
been of the least service in any case of hysteria. But that would 
not alter the facts. Individual observation is too limited to justify 
such assertions. Indeed, these arbitrary rules have very little to 
vecommencl them. I have known Aveak, nervous, delicate women 
to be disabled and bed-ridden for months and years because their 
physician obstinately denied them the little stimulus which they 
craved, and the temporary use of which would have set them 
upon their feet again, without doing any possible harm. 

So far as my own experience extends, I have found it best to 
discriminate carefully, and to prescribe one or another of the dif- 
ferent preparations of alcohol only when I could 

Qualified use of stimulants. . 

not do better, and when there was no especial 
langer of reviving an old habit, or of forming a new one which 
^ould result in intemperance. There is an essential difference 
between giving wine or brandy to the extent of complete narcot- 
ism, or endorsing its persistent use until one's patient is in a state 
of chronic alcoholism, and the judicious and temporary employment 
of it as an available stimulus in an emergency. And let me tell 
you that there is not one-hundreth part the clanger of our making 
drunkards of women that there is of making topers of men. 

The exercise should be regulated most carefully. Many women 
become fatigued almost beyond measure who, strictly speaking, 

take little or no exercise. With the majority 

Proper exercise. 1 

of these persons the fault is not that their time 
is not occupied, but that they lack the stimulus and benefit of 



SQ2 THE DISEASES OF WOMEN. 

variety of occupation. Their house-life is a species of tread-mil] 
round of work and worry, with little or no change whatever, 
What this class needs is diversion, a combination of mental and 
physical exercise that shall keep all their faculties in healthful 
play. If a woman wears out her nervous energies in household 
drudgery, you must prescribe a change of habit, and season her 
cares with a little of the spice of the outside world. Fresh air 
and sunlight, society, travel, music, literature, or an additional 
servant may be useful ingredients in your prescription. 

Among what are called the "better classes," with whom life is 
a listless, perpetual holiday, a predisposition to hysteria is fre- 
quently nurtured or acquired. With many 

Hysteria among the ,t t n ,i • v t n -, 

" better classes." women the seeds oi this disorder have been 

sown in boarding-school. Boarding-house life 
and hotel life, in America, are nurseries of hysteria. This kind 
of life subjects its victims, who are without proper and constant 
employment of their time, to vicissitudes of excitement, and of 
personal experience that are inimical to health. The nervous 
systems of these women suffer most severely. Their life is an 
aimless, artificial one, with a large margin of leisure which is apt 
to be wrongly appropriated. It is almost impossible for a gifted 
and attractive young or middle-aged lady to escape the perils of 
such a home, if indeed it deserves the name. 

And, since it will not always be possible for you to locate these 
patients just as you could wish, any more than to mate them pro- 
perly, you will be forced to counteract such 

Domestic occupation. . . . . 

influences in the most practicable manner. Ii 
they have the means and the disposition, persuade them, if pos- 
sible, to settle in homes of their own, where proper domestic 
cares may occupy a share of their time and attention. Thousands 
of women would be cured of the hysterical tendency if they 
were blessed with comfortable homes, and removed permanently 
from the corrupting influences to which they are otherwise sub- 
jected. It is sometimes absolutely essential to remove them from 
a house in which everybody knows everybody's business, and in 
which no woman has any business. You can also accomplish a 
great deal by the exercise of a little tact in keeping these patients 
busy with something useful, instructive and profitable. One may 
perhaps become interested in a course of reading which you 



HYSTERIA. 803 

shall map out for her. Another might be made to forget her com- 
plaints if she were to resume her music, her 
m entaf habit" of pr ° per French, or her German ; or to participate in 
one or another of the charitable objects and 
missions, in which some of the best women of our day are so 
much engrossed. One should see more of society, and another 
less. All need some kind of diversion, some mental occupation, 
some change which shall divert their thoughts from themselves, 
and especially from a morbid stimulation and gratification of the 
sexual appetite. 

You will sometimes have to counteract such domestic infelicities 

as, by the constant fret and friction which they induce, serve to 

keep those who are predisposed to hysteria, 

^Remove domestic infelici- alwayg Qn ^ ^ ^ rj^ woman may be 

cured by getting her out of sight of her own 
servants ; and that one, if she can escape the neighborhood in 
which she is certain to see or hear something of others, men or 
women, against whom she has conceived an inveterate dislike. 

The hysterical irritability is very apt to accompany, or to be 
engrafted upon a jealous and unhappy disposition. It certainly 

is much easier to prescribe than to furnish con- 

Contentment. 

tentment to such persons, but example and pre- 
cept will accomplish wonders, even although, like the third party 
who attempts to make peace between man and wife, we some- 
times incur considerable risk in giving our advice. In all this 
you will be compelled to take a leading character in the old play 
ol Tact versus Talent. And I am anxious that you shall not 
appear upon the stage of practical life as physicians without ever 
having had a rehearsal. For, in the cure of hysteria especially, 
the largest share of the work to be done may depend upon these 
common-place matters. 



LECTURE XLIX. 

TREATMENT OF HYSTERIA. CONCLUDED. 

Treatment during' the fit. Do. for the hysterical diathesis; do. for the accompanying: 
lesions and complications. Case.— The utero-gastric and cardiac disorders. Case.— 
Hysterical hemiplegia. The hysterical mimicry. Treatment. 

From the time of the Greek midwives, who, according to Galen, 
were the first to employ the word Hysteria, its treatment has been 
divided into that proper for the paroxysm and that for the 
interval. 

When you are called to relieve a woman who is in " a fit of 
hysterics," you must know what to do. First, you should be self- 
possessed, and not in a flutter. Allow nothing 

Treatment during the fit. . 

to surprise you. Be cool and collected. Look 
upon the most startling developments as matters of course. Do 
not give a hasty opinion as to the result. Qualify your prognosis, 
and above all things do not be in a gloomy, despondent sta,te of 
mind yourself. Have the patient placed in a comfortable position 
upon the bed or sofa. Let the head be slightly raised, and if 
need be, held by an assistant. Have the forehead and face bathed 
with cool or cold water, or cold compresses laid across the fore- 
head and temples. Let her have a plentiful supply of fresh air. 
If it blows from the window directly into her face, so much the 
better ; or she may be fanned by the nurse. All ligatures in the 
form of corsets and garters, etc., should be removed. The dress 
should be thrown open at the throat especially, and only enough 
force applied to keep her from inflicting bodily injury upon herself 
and others. 

The usual restoratives consist in allowing her to smell of ordi- 
nary spirits of camphor, ammonia, musk, cologne water, chloro- 
form, ether, alcohol, vinegar, the fumes of a 
burning feather, or of a lighted match. Sina- 
pisms and the warm foot or sitz-bath, vigorous rubbing by a strong, 
healthy person, dashing cold water upon the head or spine, the 
application of heat, electricity, and the use of brandy, coffee, cam- 



HYSTERIA. 805 

phor, sulphuric ether, ice water, or a solution of some salt of vale- 
rian by injection into the rectum, are among the available expedients, 
which may be tried before the patient is able to swallow. Some- 
times the paroxysm Avill be relieved almost immediately by firm 
pressure upon the hypogastrium. More frequently it will pass 
away insensibly under the influence of delicate attention and quiet, 
and proper sympathy which tend to soothe and calm the excited feel- 
ings. Or it may terminate by your sending out of the room some 
person who is well enough disposed, but who is especially obnox- 
ious to the patient. 

If the fit has been induced by anger, or some fancied slight, or 
disappointment, or by mental anxiety or grief, no allusion to the 
cause or to the possible consequences of the 
attack should be permitted within hearing of 
the patient. Indeed, the greatest care should be taken to turn 
the current of conversation, if there is any in the room, into quite 
another channel, else it may prolong the disorder. Whatever is 
said should be calculated to divert her attention from herself, and 
thus indirectly to restore the will to its supremacy over the emo- 
tions, for when the will of the patient is in league with the emo- 
tions it adds fuel to the flame to persist in telling her how very ill 
she is. The better plan is to speak of something quite foreign to 
her present condition and surroundings, and to try to interest those 
who are present in the subject matter of conversation. This will 
be a mild means of counter-irritation, or diversion, which will 
.serve to benefit the patient, who is unwittingly being toned down 
by your tact. 

It is the habit of some physicians to scold such a patient, or to 

declare contemptuously that she has " nothing but hysterics," and 

to refuse to do anything for her. This is posi- 

Don't scold. . . ° - i ., . 

tively and unprolessionally cruel, lor, while it 
lasts, the suffering is as real as in any other disease, and the 
patient as deserving of sympathy and relief. Doctors are servants. 
And whether you are sent for in the middle of the night, or while 
at church, or at a social party, to visit an hysterical patient, you 
should carry with 3-011 as large a measure of good-nature as if you 
were going to a case of puerperal peritonitis, or of some other 
serious disease. 

Most frequently, however, the paroxysm will have ended before 



806 THE DISEASES OF WOMEN. 

your arrival. If she remains obstinately silent and refuses to an- 
swer your questions, give her the medicine, 

For her taciturnity. . c 

and w^ait until she gets ready to speak. This 
let-alone species of indifference on your part will hasten the crisis, 
and after a fit of weeping, she will be communicative enough. 

Concerning the treatment between the paroxysms, I wish in 
the first place to insist that you shall not be misled by the inci- 
dental and irrelevant symptoms which are so common in all forms 
of hysteria. I have often thought that if it 

Treatment in the interval. ,. . 

were possible to treat our hysterical patients 
just as we are compelled to treat infants when they are ill, that 
is, without regard to their subjective sensations, the special treat- 
ment of this disease would be greatly simplified and much more 
successful. For it is the peculiar rendering, the exaggerated esti- 
mate, the misinterpretation of the sufferings experienced, that 
will sometimes lead you to wish that such a patient was as mute 
as a child that is only a month old. 

I know that it is very difficult to discard worthless symptoms 
without at the same time eliminating some which are really valu- 
able and important, and yet, I tell you frankly 

Necessity for caution in , -i , • n , • ■ -" n ,1 

the exclusion of symptoms, that, in my judgment, a majority ot the symp- 
toms, more especially those derived from the 
tongue of an hysterical patient, are of no practical significance 
whatever. You cannot depend upon them. They are compounded 
of shrewdness, cunning, trickery, deceit, a mor- 
May be too kaleidoscopic bid imagination, real suffeiinof, and reflex irri- 

to be covered by any single ° ° 

remed y- tions of all kinds, which confuse and confound 

us at every turn. One of my medical friends says 
that a hysterical patient is " a pathological kaleidoscope/' It is so ab- 
solutely impossible to prescribe for the totality of the symptoms 
that, in many cases of hysteria, you will be compelled to abandon 
the idea ; for when they change like the hues of the chameleon, 
and are as irreconcilable, incompatible, and contradictory, as they 
often are, you would need as many remedies as there are single, 
individual symptoms, and these might have to be changed several 
times daily. 

As a prospective improvement upon the ordinary unsatisfactory 
and unsuccessful method of combating -hysterical symptoms, let 
me counsel you to direct your treatment, 1st, Against the hysteri- 



IIYSTERI*. bOT 

cal diathesis, and 2d, Ayainst the symptoms which properly belong 
to the lesion, of which the hysterical attack is 

General rules. , .~ 

either the consequence or the concomitant, rhysi- 
cians recognize the practical significance of the rheumatic, the 
gout}', the tuberculous, and the syphilitic diatheses. In the treat- 
ment of almost every variety of disease of which their existence 
can possibly complicate or modify the symptoms, the}' receive due 
consideration when we make our prescriptions. The hysterical 
predisposition is equally pronounced and equally deserving of at- 
tention. Its treatment is more decidedly hygi- 
//I°i. the hystericai dia ~ enic and prophylactic, than medicinal. It pre- 
scribes the removal, if possible, of all the causes 
which might originate or perpetuate this disorder. It regulates 
the mental and physical exercise of the patient, her habits of eat- 
ing and sleeping, her social and domestic life, and everything, in 
short, which can influence the functional operations of her ner- 
vous system. It places particular stress upon these matters in her 
case because of her constitutional bias towards hysteria. It recog- 
nizes that health cannot be restored unless the proper physiologi- 
cal conditions for its restoration and maintenance are supplied. 

A knowledge of this diathesis will sometimes aid in the selec- 

tion of our remedies. The relations of belladonna, ignatia, 

caulophyllin, agaricus, hvoscvamus, lilium tig., 

Remedies to counteract it. *~ 

gelsemmum, ether, moschus and valerian to this 
peculiar predisposition are well known to the profession. They 
tire sometimes given with excellent effect as hysterical prophylac- 
tics, and may finally eradicate the disease altogether. As inter- 
current remedies they maybe equally useful. The choice between 
them will depend upon a few '•' characteristic," objective, cardinal 
symptoms. 

The diseases of the generative system are the most usual con- 
comitants of hysteria. Disorders of menstruation underlie a large 

proportion of the cases of this disease. Dys- 

Coincident menstrual dis- l i , • 

or ders. menorrncea, amenorrncea, too scanty, too copi- 

ous, irregular and too frequent menstruation may 
need to be cured before the symptoms of hysteria will disappear. 
For each of these affections you should therefore prescribe as care- 
fully as possible, taking only such note of the hysterical outgrowth 
as will enable you to counteract the predisposition of which I have 



808 THE DISEASLS OF WOMEN. 

spoken. The chief thing is to cure the menstrual irregularity, 
after which the contingent symptoms will disappear of themselves. 
Remove the cause and the effect will cease. Cure the idiopathic 
lesion, and the sympathetic, nervous, accidental symptoms will 
vanish. 

This method of procedure will enable you to discriminate be- 
tween the legitimate symptoms, which are reliable, and those 
which are not. It will not, however, do away 
ie Jdma?r s f ympto d ms 0f the with the necessity for close and careful study 
of those symptoms, and a proper adaptation of 
the remedy to the cure of the menstrual difficulty. You will 
proceed to remedy that disorder, whatever it may be, with little 
or no regard to the hysterical phenomena, however noisy and 
clamorous they are. 

The same rule applies to organic disease of the ovaries, and of 
the uterus, to uterine displacements and ulceration, to hypertro- 
phy and neoplasms of the womb, to leucorrhcea, 
ut£u?, c ivlrie S e , S etc. softhe abortion and its. consequences, to vesical and 
rectal irritation, inflammation and ulceration, 
which so frequently exist in connection with hysteria. The symp- 
toms that properly belong to these several affections are those 
which are most significant, and which will afford the real indica- 
tions for the cure of the case. There is no objection to an inter- 
current remedy for the relief and removal of a contingent delirium, 
globus or clavus hystericus, the hysterical stitch in the side, or 
the infra-mammary pain ; but your chief concern will be to recog- 
nize and cure the lesion from which so many of the symptoms are 
proliferated, but upon which they are in a sense supernumerary. 

So, also, with the gastro-alimentary, hepatic, cardiac, cerebral, 

spinal and renal difficulties which sometimes attend upon hysteria. 

These complications render it still more difficult 

Also of other organs, -i r> 

which are themselves sec- to cure, v or they may be, and often are, them- 
selves secondary upon some inter-pelvic disor- 
der. Under these circumstances you will be compelled to analyze 
the symptoms, to go back to their first cause, and in selecting the 
remedy, to recognize the relative importance of the uterine and 
the ovarian symptoms. 

For example, in a case of utero-gastric or utero-cardiac disorder, 



HYSTERIA. 80y 

the symptoms that are referable to the pelvic viscera may afford a 
more reliable guide in the treatment than the 
c a JdSc°2 a ringem n ent" tero " gastric or the cardiac symptoms, separately con- 
sidered. One of my patients had an intractable 
pniesis Avhich the best chosen internal remedies failed to relieve. 
In addition to the vomiting, she had a great 
variety of hysterical symptoms, which alarmed 
her family exceedingly. Feeling confident, at last, that in her 
case the remote cause was located within the pelvis, I proposed a 
vaginal examination. The touch revealed the uterus badly pro- 
lapsed. It was replaced and kept in position, and not only did 
the vomiting cease, but the hysterical symptoms also were cured 
from that moment. 

Another lady suffered from violent attacks of palpitation of the 
heart. Her physician had decided that she really had organic dis- 
ease of the heart. These attacks of palpitation 
followed riding, walking, defecation and coitus. 
They had occurred repeatedly at intervals for more than three 
months, when I was called to see her. The nervous system had 
become so much involved that these paroxysms finally merged 
into a species of hysterical fit. Vaginal examination with ihe 
speculum disclosed an abrasion of almost the whole of the ante- 
rior lip of the os uteri. I applied the oleaginous collodion a few 
times, ordered her to keep off her feet, and in a fortnight the heart 
disease and its hysterical outgrowth had entirely disappeared. She 
has had no return of either affection within the last three years. 

These cases are exceptional, but they will serve to illustrate the 
importance of striking at the root of the real difficulty, when it 
is possible, instead of contenting yourselves with lopping off a 
branch here and there in the shape of an impertinent symptom, 
or class of symptoms. 

Hysteria occurring at the climacteric period, or during preg- 
nancy, labor, the parturient state, or lactation, 
didons" compllcating con_ w ill need to be treated with especial reference 
to these states or conditions, which are prime 
factors in the production and modification of its symptoms. 

During the winter I shall have frequent occasion to elaborate 
and apply these general rules for the treatment of Hysteria. I 
will therefore spare you the infliction of a lecture upon its special 



810 THE DISEASES OF WOMEN. 

therapeutics this morning. In the present connection it must 
suffice to remind you that it is one thing to put an end to the 
hysterical fit, by the use of such expedients as any old nurse could 
suggest and apply, and quite another thing to treat the various 
forms of this disease intelligently, thoroughly and successfully. 
For no other affection is so complicated, so enigmatical, so per- 
sistent, and so trying in every respect. And yet there is no other 
more amenable to rational, persevering and appropriate treatment. 

[In a recent lecture on neurasthenia in a hysterical subject, 
Prof. L. said that many of the mental symptoms were distinctly 
referable to a state of permanent congestion of the pelvic organs, 
with a coexisting anaemia of the brain or of the spinal cord. The 
cerebro-spinal anaemia in these cases is likely to be increased by 
Neurasthenia. tne ^ oss °^ blood at the month, and by the 

weakened condition of the digestive function. 
This is often the real state of things in the hysterical neuroses. 
In the young gill it is developed from brain-fag in the boarding- 
school, and from sedentary and luxurious habits at home, where 
dress and inaction determined intra-pelvic congestion and men- 
strual derangements. In married women the same train of symp- 
toms are exaggerated, and back-ache, headache, womb-tire, weari- 
ness and physical dilapidation are the result. 

Sometimes, and especially toward the climacteric, and in women 
of a highly intellectual cast, these conditions of local hyperemia 
and anaemia are reversed. The cerebro-spinal axis is surcharged 
with blood, while the pelvic viscera are not supplied as freely as 
they should be. But here also are nervous symptoms that are 
peculiar and very difficult of cure. 

The general remedies for this peculiar form of hysterical 
neuroses includes the careful use of electricity ; of massage, with 
friction, kneading, tapping and percussion; of the motion of the 
joints and their extremities ; of good feeding and of seclusion from 
every one but the physician and the necessary attendants.] 

HYSTERICAL HEMIPLEGIA. 

Case. — Mary J , aged 29, seamstress, unmarried, had 

been in poor health for more than a month, complaining of head- 
ache, fatigue, debility, drowsiness, loss of memory, and disinclina- 
tion to work. Two weeks ago she was suddenly seized during the 
night with a violent fit of hysteria. The spasms of the voluntary 
muscles were very severe. She talked foolishly of her little 



HYSTERICAL HEMIPLEGIA. 81 i 

love affairs, of church matters, and upon all kinds of topics. 
In about half an hour the paroxysm passed off with alter- 
nate laughing and crying, and finally with the escape of a large 
quantity of colorless urine, The next morning her right 
arm and leg were paralyzed. The muscles were relaxed. She 
could move the leg a little, but only with the greatest effort. 
The arm was quite powerless. Her consciousness was complete, 
and had been from the subsidence of the fit. The face Avas not 
paralyzed, nor did the tongue turn to the right angle of the mouth 
when she protruded it; her speech was unimpaired, but it was 
sometimes difficult for her to sAvallow. She complained of frontal 
headache and inability to sleep. The right pupil was considera- 
bly enlarged, but the left one remained unaltered. The bowels 
were obstinately constipated. 

The menstrual flow, which had begun only a few hours before 
the hysterical attack set in, was arrested, and did not return. 
She has been subject to amenorrhcea, and sometimes passes several 
months without any " show." She has frequently had hysteria in 
a mild form, but these paralytic symptoms are new, and have 
alarmed both herself and family very much. 

This case is apropos to the preceding one. It furnishes another 

illustration of the hysterical mimicry of which I have already 

spoken. One would say, at first thought, that 

Hysterical mimicry. . 

it would be quite impossible tor this or any 
other affection to imitate so grave a disease as hemiplegia. But 
here you see a case in which the right half of the body is power- 
less. This poor girl had to be carried into the amphitheatre, for 
she cannot stand alone. When she attempts to walk, the right 
limb, which seems a little stronger than it was at first, swings 
with a pendulum-like motion, directly forwards and backwards, 
but its abduction and adduction are impossible. You will observe 
that the arm hangs helpless by her side. 

There is an evident paralysis of the nerves of motion. Let us see 
if the nerves of sensation are in the same state. For these two forms 

of palsv have no necessarv relation to each other. 

A practical test. 

Observe that when 1 stuck the pin into her 
arm, to test this question, it was done without her knowledge. 
If I had told }'Ou in her hearing what I intended to do, and she 
had seen the point of the pin coming towards her, she would 
have imagined that she felt it, whether she really did so or not. 
We must be cautious in these little matters. I once introduced 
a sound into the female bladder, and on turning it about observed 



&12 THE DISEASES OF WOMEN. 

a clicking noise, which exactly resembled that caused by the 

striking of a metallic instrument against a calculus, which disease 

she was supposed to have. Having withdrawn the instrument, I 

was about to declare that my patient had stone 

Caution. •iTiii l ••in 

in the bladder, when, upon turning its handle, 
I discovered that it had become loosened and gave forth precisely 
the same click that I had heard before. This shows the impor- 
tance of being always on our guard, lest we arrive at wrong con- 
clusions in diagnosis. 

Naturally enough you w r ould like to know what variety of 
unilateral paralysis it is from which this patient is suffering. I 

have no doubt but that it is hysterical, and my 

Diagnosis. , 

judgment is based upon the following reasons. 

1 . She is of the hysterical temperament. This peculiar constitution 

is as different from the apoplectic habit as the scrofulous cachexia 

is from the sanguineous temperament. The fact that she has 

been subject to hysteria before precludes the 

probability that her paralysis is due to effusion, 

either of blood or of serum, within the cerebro-spinal cavity. 

2. Hysterical attacks commence abruptly, and are not accom- 
panied by marked signs of congestion, fever, coma or constitu- 
tional disturbance. There are no lesions of the perceptive 
centers in hysteria, as there are in apoplexy, whether it be ner- 
vous, serous, or sanguineous. 

3. The relation of the menstrual arrest to the initiatory parox- 
ysm. A mere suppression of the menses in one of her slender 
form and delicate organization would not be likely to induce such 
a determination of blood to the head as to result in apoplexy, or 
such a disorder of the cerebral nutrition as, in the short space of 
a fortnight (more especially in one so young), to cause softening 
of the brain. In such subjects as this the menses are very apt to 
be scanty and irregular. Hysterical paralysis is more frequent at 
puberty and the change of life, when these particular crises influ- 
ence the general nervous system so decidedly, than at other 
times. 

4. The sweeping motion of the leg, and the absence of paraly- 
sis of the face and tongue, enable us to exclude the more ordinary 
forms of hemiplegia, and to identify the hysterical variety. 

Other signs are classed as diagnostic of this singular affection. 



HYSTERICAL HEMIPLEGIA. 813 

Among them are the ability to move the palsied extremity under 
sudden and powerful emotional impulse. Such 

Other differential signs. . , , n 

a patient may sometimes be so shocked or start- 
led as to use the limb automatically, and without thinking of what 
she is doing. One of my neighbors, who had not walked a square 
for months, left her bed suddenly, the night of the great fire in 
this city, in October last, and marched three miles in order to 
save her life. 

If the patient feigns paralysis of the arm especially, you will 
observe that when she stoops forward she keeps it close to her 

side. In absolute paralysis of that member it 

Position of the arm. -i -i i • mi^i ,t r i 

would be impossible lor her to do so, lor, hav- 
ing no voluntary control over it, it would fall forward when she 
stoops towards the floor. 

Another distinguishing peculiarity of the hysterical paralysis is 
that there is very little atrophy of the muscles of the affected part. 

If the arm or the leg, or both, are helpless and 

Absence of atrophy. 

useless tor months, their size is not so apt to 
be diminished as in ordinary palsy. The limb does not become- 
shrunkp'"> and attenuated, but remains as plump and fleshy as the 
soul_ ^ne. 

In many cases, the hyterical fits recur from time to time, with 
or without choreic movements of the other voluntary muscles. 
Sometimes there is an incidental aphonia, and globus liystericus is 
the rule and not the exception. 

Hysterical hemiplegia is not a very common form of paralysis. 
Hysterical paraplegia is more frequently seen. In the former it 

is said that the left side is more apt to be affect- 

Mav occur in males. 

ed than the right one. Being largely the result 
of emotional causes, there is no doubt that it may occur in men as 
well as in women. Indeed it is very probable that a large pro- 
portion of the cases of paralysis that are cured by itinerant pre- 
tenders through the "laying on of hands," animal magnetism, and 
every species of mummery, are hysterical, functional, emotional, 
circumstantial, self-limited, and not dependent upon any struc- 
tural lesion whatever. 

Unless the disease is complicated with some serious lesion, 
either of the brain or spinal cord, the prognosis is generally favor- 
able. It may require a long time to effect a cure, but the patient 



814 THE DISEASES OF WOMEN. 

and persistent use of the proper means will ultimately succeed. 
In many cases the affection leaves as abruptly 

Prognosis. . 

as the hysterical aphonia or meteonsm are apt 
to do. If the paralysis comes on during the climacteric, the more 
or less serious nature of the incidental disorders, and the condition 
of the general health Avill modify your judgment of its severity. 

Treatment. — - The auxiliary treatment of this affection is very 
important. It includes the proper employment of friction, elec- 
tricity, animal magnetism, the movement cure, 
the health-lift, Faradization, bathing, and ex- 
ercise, both physical and mental. It prescribes fresh air, sun- 
light, change of scene, travel, pleasant and agreeable society, good, 
healthy, and nourishing food, and the careful use of stimulants. 
It orders the removal of whatever may cause her to become impa- 
tient and irritable, or that can in any way disturb her mental equi- 
librium. 

Ignatia, gelseminum, belladonna, secale cornutum, cuprum, 
plumbum, rhus tox., coccuius, causticum, baryta 

Internal remedies. . 

carb M caulophyllm, phosphorus, and zincum me- 
tallicum, are the remedies most frequently indicated. 

A ready expedient for the detection of hysteria consists in the 
application of pressure which has the effect to 
A pe diigno& nt in shorten the paroxysm or to solve the diagnostic 
riddle if the disease is not paroxysmal. One 
method is to press firmly with the thumbs over the supra-orbital 
notches, no matter what struggles the patient may make. Another 
is to press upon the ovarian region, or upon one or another of the 
hysterogenic points of Charcot until the fit is arrested, or the mus- 
cular and mental symptoms are controlled. Pressure upon the 
abdomen, and even in the inguinal region, will arrest the hysteroid, 
the hysterical and the hystero-epileptiform fit in boys and men as 
well as in women. 



LECTURE L, 

SPINAL IRRITATION — NOTALGIA. 

Spinal irritation, bsck ache. Case.— Causes, predisposing and exciting-, traumatic and 
nervous. Symptoms, reflex and direct. Spinal irritation and uterine disease. Diag- 
nosis in post-traumatic cases, difficulties of, from myelitis. Prognosis. Treatment 
for the mensirual, rheumatic and neuralgic, complications, local treatment, Faradiza- 
tion. Physomctra. Case.— Causes. Diagnosis. Treatment. 

Some of the more advanced members of the class have fre- 
quently consulted me with regard to the treatment of spinal irri- 
tation. This woman has suffered from that disease for many 
years, and her clinical history will doubtless interest you. 

Case. — Mrs. M., aged fifty, enjoyed excellent health until her 
eleventh year. At that time, while running at play, she fell and 
struck the back of her neck against the corner of a table. The 
blow was upon the most prominent of the lower cervical vertebrae, 
(vertebra prominent). In consequence of this injury she Avas for 
six Aveeks very ill in bed, and so extremely weak and sensitive 
that they had to move her on a sheet. Several months elapsed 
before she could wear a dress. She finally got around again, 
but for several years her physicians did her but little good, and 
none of them referred her poor health to the injury that she 

had received. Finally, another physician, Dr. , while visiting 

her mother one day, touched the spot where the blow was received 
upon the neck, and she suddenly fainted away- Then followed a 
thorough course of blisters, with tartar emetic dressings, cups, 
leeches, and four years of barbarous treatment, which to think of, 
makes her "shudder to this day/' With this treatment, there 
was much sloughing of flesh from the back, which is all scarred up 
now. It was a regular field-day when these sores Avere dressed. 
She cried, her mother cried, and all hands cried, but they could 
do no better, and she facetiously says, "it was equally impossible 
to do anything worse.'* In consequence of this injury, the left 
foot and limb were changed, the heel being drawn up as in a form 
of club-foot (pes equinus), in Avhich position it remains. 

She did not menstruate until she had reached her eighteenth 
year, and then only once. She "never saw anything again" until 
after she was nineteen years old. From the time that menstrua- 
tion was really established, she began to improve, and kept toler= 

S15 



816 THE DISEASES OF WOMEN. 

ably well. At twenty-two she was married, and for eighteen 
months more her health remained pretty good. Then she skipped 
one month, and was supposed to be pregnant. At the eighth week 
she began to flow excessively. The haemorrhage continued, better 
and then very much worse, without interruption for two months 
more. Despite this flooding, her size increased until she measured 
one and one-quarter yards (forty-five inches) around the body 
over the abdomen. She was said by the physicians to be four 
months advanced in pregnancy. 

The flooding reduced her to death's door, and was not relieved 
until labor pains came on and continued severely enough to expel 
an enormous mass, which proved to be hydatids. With this mass 
many gallons of water were also discharged. The mass consisted 
of small bodies, which, ''varied from the size of a pea to that of a 
walnut, and which were strung together like grapes upon a stem." 

Two months elapsed before she could sit up. The lower limbs 
became powerless, and remained as if paralyzed for many weeks. 
In a little while the most severe and agonizing headaches com- 
menced. These recurred frequently, and kept her ill the whole 
summer. They were excruciating, and so severe that u it seemed 
as if she would go crazy with them." 

In eighteen months more her first child, a son, was born. In 
two years from his birth she had another child, which did not live 
but a year ; and in five years her third and last child, a daughter, 
was born. In every instance pregnancy and labor 'were normal 
in all respects. The labor was very severe, averaging about 
twenty-four hours, and the children were large. Her first and 
third children are still living. 

When she had been married thirteen years, she received a 
second injury. While on her way to church, and walking on an 
icy place down hill, her feet slipped from under her and she fell. 
She thought of her back and neck, and "tried to save them." 
For this reason she struck upon her right elbow and her head 
was twisted backwards. She was lifted upright, and, with a 
woman's courage, walked home again. When she got up her 
head was fixed backwards, the muscles of the neck were rigid 
and spasmodically contracted, so that she could not turn the head 
or straighten it without taking hold, as she did, with her hands 
upon either side, and forcibly bringing it into position. When it 
turned, "something cracked as if a bone had suddenly gone into 
place." To this day she can not look up to the ceiling without 
supporting her head from behind with her hands. 

In consequence of this second accident she was kept in bed for 
about three months. The head could not be moved except by 
others, or rather excepting by her husband and one lady friend. 
This had to be done most carefully else it brought on paroxsysms 



SPINAL IKRITATION, ETC. 817 

of screaming, and agony that was almost unbearable. The head- 
ache returned, but in a different form. The first symptom of an 
attack was a feeling "as hot as fire almost," in a spot on the top 
of the head. If the husband began early and promptly when this 
burning commenced, to rub first over the spot and then to follow 
along down the body and extremities, the pain in the head would 
vanish. 

From that time until now, the region of the spine, for the space 
of nearly an inch on either side, and running from the base of the 
skull to the last dorsal vertebra, has been so exquisitely tender 
that the weight of a feather brush would excite the keenest suf- 
ferin?. Even if one should point the finger towards the back it 
would make her "scringe." 

The lower part of the spine has remained perfectly well. In no 
sickness that she has ever had, so her husband says, has her mind 
seemed to be affected in the least. She has frequently been un- 
conscious and oblivious to passing events, but never in the least 
delirious or " out of her head." 

Before the birth of her last child, and for a short time only, she 
had some pain with menstruation. With this exception, she has 
never had dysmenorrhcea, or indeed any " female weakness " of 
any kind. The spine is not as straight as it should be, but is 
curved posteriorly at a point midway between the shoulders. She 
can lie best upon her back, and could do so during all her sick- 
ness ; but, on account of pulling sensations in the opposite direc- 
tion, cannot lie upon either side. At times the head has felt very 
heavy, as if the shoulders could not sustain it, and as if it pushed 
directly downwards toward the body. It is impossible for her to 
sit upright without something to lean her head against. She can 
use her hands from the wrists automatically, providing her head 
and body are snugly fixed and padded, and there is no necessity 
for moving them.- 

Beside the experiences in falling she has incurred other risks, 
among which was the swallowing of a tea-spoonful of the strong 
tincture of iodine, which a druggist's clerk had put up for Indian 
hemp ! Opium throws her into violent, frightful spasms, which 
last for days. She once suffered severely in this manner from 
taking a small quantity of this drug contained in a cough mixture. 
She cannot bear either very cold or very warm weather. Her 
worst attacks of prostration always occur in the winter and spring, 
generally in the months of February and March. 

The menstruation is becoming scantier, the flow is very debili- 
tating and very irregular. As she approaches the climacteric her 
general health is somewhat improved. 

Here is a case that would puzzle a clairvoyant. A spinal in- 
jury of a very serious nature is received at the impressible age of 



818 THE DISEASES OF WOMEN. 

eleven years. Its effect is to delay the establishment of the 
menstrual function. While the system is suffer- 
mg, not only from the traumatic lesion of the 
spinal nerves and muscles, but also from retarded puberty, she is 
placed under such treatment as would undermine and ruin the 
health of the strongest person. This voluntary martyrdom was 
continued for four long years. And } r et she lived. At eighteen, 
when she had discontinued these barbarities, Nature renewed the 
attempt to establish the catamenia. The flow came once, but Avas 
not repeated for more than a year. After her marriage she be- 
came pregnant as she supposed, and the doctors insisted. Then 
after two months of flooding on her part, and of blundering on 
theirs, she is finally rid of a hydatid mass. Months elapsed and 
she barely survived. Then followed the birth of her three 
children. 

After thirteen years of married life she sustained the second in- 
jury, while on her way to church. (Perhaps it has never oc- 
curred to you that the men are almost never injured on their way 
to church.) Then the fearful suffering with the crampings in 
the muscles of the neck, the hyperesthesia of the superior spinal 
region, the headache, and the confinement in bed for several 
months. And, finally, the incidental vicissitudes and experiences 
so common to the female portion of humanity. This is but an 
outline sketch of thirty-nine years' experience on the part of this 
good woman. 

Causes. — Spinal irritation, as it is styled for the lack of a bet- 
ter name, most frequently arises from a traumatic injury, as, for 
instance, from a direct blow, or a fall upon 

Traumatic causes. . . 

some portion of the spinal column, or from a 
railway jar, or contusion. Of course men and women are alike 
subject to such accidents. But in women, who are more deli- 
cately organized, whose spinal muscles and 
predfspon r ent^ gaRization a neryes are softer and more susceptible of injury, 
the first shock is more severe, and its secondary 
effects are more lasting and permanent. Add to this the peculiar 
impressibility of her general nervous system, in many cases amount- 
ing to a decided hysterical predisposition ; and the perturbing influ- 
ences of the crises through which she is always passing, or is about 
to pass, and we find there are especial reasons why she should 



SPINAL IRRITATION. 819 

suffer more severely, and why such mishaps are more difficult of 
cure in her case than in men. 

The full significance of this idea is not apparent at first. Not 

only does it concern the fact that women are especially prone to 

this kind of martyrdom, but that a large meas- 

Practical inference. 

ure of their consequent suffering and mal-treat- 
ment is due to ignorance thereof. "What a woman wants more 
than anything else when she is ill, is sympathy. And if her dis- 
ease is largely nervous, there is still greater need for this kind of 
universal emollient. But her family and friends are usually the 
iast to realize how a slight fall, blow or shock, can so completely 
unhinge and demoralize her physically. They talk about resolu- 
tion and will on her part, and insist that she shall get up and go 
around, make some effort to throw off this incubus, and develop 
strength by the use of it. As a rule, the stronger they are, and 
tne more muscular, the less their sympathy with this class of 
patients. This, of course, reacts upon the victim, and she can 
not accomplish what might be possible under different circum- 
stances. > 

A similar mis;udgment on the part of the physician may lead 
him to adopt such a means of treatment and of exercise as shall 

only add fuel to the flame. This happened in 

A common error. 

the case of Mrs. M. While her nervous sym- 
pathies and susceptibilities were at their utmost tension, she was 
put upon the rack and tortured afresh. Her physician made no 
allowance for sexual impressibility and excitability, and hence the 
means employed were fitted to increase her suffering rather than 
to alleviate it. 

There can be no doubt that the doctor did the best that he 
<30uld "with the light he had;" but it was the dark lantern of 
empiricism that he carried. He evidently mistook the case for 
one of spinal meningitis with effusion. But in this he was in 
error ; for whatever direct injury of the meninges may have fol- 
lowed the first fall, received some years before, the symptoms 
showed clearly enough that dropsy of the cord was not the real 
cause of her illness at the time she fainted from pressure upon 
the spinous process of the cervical vertebra. If any considerable 
effusion had existed and continued for so long a time, there must 
have been chronic and complete paratysis. 



820 THE DISEASES OF WOMEN. 

The very fact that puberty was arrested, without any intra* 

pelvic lesion, and that menstruation came on spontaneously when 

the treatment was suspended, shows that the 

Of nervous origin. 1 . . 

disorder was mainly, it not altogether, of a 
nervous character. And whatever had a tendency more and 
more to derange her nervous system could only produce further 
irritation, perturbation and unrest. The marvel is that she sur- 
vived such unskilful and harmful treatment at all. 

Other causes of spinal irritation are strains, as from lifting, or 
jumping, lying, sitting or standing habitually in such a posture as 

to keep the spinal muscles on the stretch, and 

Exciting causes. ^ 

thus to weaken and paralyze them. Rheuma- 
tism and neuralgia being predisponents of this disease, persons 
who have either of them are more or less decidedly susceptible 
to changes in the weather. For this reason, among others, as 
with our patient, extremes of heat and cold, and more especially 
of dryness and moisture, influence it greatly. The jar of travel 
by rail, in a rough carriage, or upon horseback, may induce it. 
And so, also, of tight lacing, the wearing of high-heeled shoes, 
and of articles of dress which are fastened at the waist and not 
hung upon the shoulders. 

Symptoms. — The symptoms are almost endless in their variety. 
If the disease has been caused by direct traumatic injury of the 
spine, the most severe pain will be located there, and we may 
accordingly find the suffering referred either to the lumbo-sacral,. 
the dorsal, or the cervical region. 

If it is in the sacral region the pain will be less acute than 
when it is higher up along the vertebral column. It will be dull, 
aching and heavy in character, with complaint 
re ^™™ in J ur y in the sacral 0I> g rea t weariness, exhaustion, and perhaps of 
numbness also. The patient wishes something 
to be pressed "into the hollow of her back," or to have her hips 
rest firmly upon something for support. She often stuffs a pillow 
or her shawl, or something of that kind, beneath her, or behind 
her, to rest her back and to give her ease. These pains are often 
accompanied by intra-pelvic pains, bearing down and distress, as 
if the womb were displaced. Indeed, they are often wrongly 
attributed to some slight and temporary deviation of the womb, 
and the attempt is made to cure them by pessaries, injections, etc. 



SPINAL IRRITATION. 821 

When the results of the injury, or the lesion, if there is one, 
are located in the dorsal region, the pain is more acute, with super- 
sensitiveness of the skin over the spinous pro- 
re? °n m injuryin thedorsal cesses of the dorsal vertebras. Sometimes these 
processes are exquisitely tender to the touch. 
Direct pressure upon them, although it may be slight, may cause 
her to fall, to faint, to vomit, or to shriek as if she had been shot. 
I have seen two cases in which the pain produced in this way was 
compared to that from stabbing with a very sharp knife. The 
dorsal vertebrae are most frequently affected. 

If the blow has been received, or the injury clone to the spine, 

in the cervical region, the pain and soreness will vary according 

to circumstances. The suffering is apt to be 

From injuryin the cer- y er y severe. Sometimes the arms become pow- 

vical region. J J- 

erless from injury of the nerves which consti- 
tute the brachial plexus. Other branches of the cervical nerves 
being injured by the blow or the shock, the muscles of the back 
part of the neck are more or less implicated. These muscles, 
which }^ou know are very numerous, including the splenius colli, 
splenius capitis, cervicalis ascendens, transversalis colli, the tra- 
chelo- and sterno-mastoid, complexus, spinalis cervicis, trapezius 
and the obliquus superioris, are those which were spasmodically 
affected in the case of our patient, It was the painful cramp or 
contraction of these muscles that caused her head to be almost as 
immovably fixed as it is in torticollis, or wry-neck. Pressure upon 
the tender cervical vertebra may even stop the pulse at the wrist. 
When the symptoms are produced by other than mechanical 
causes, they are usually less intense but more erratic in their 
nature. The spinal tenderness is more diffuse. 

From incidental causes. . . 

It may be located m any portion of the back 
from the occiput to the point of the coccyx. Light pressure on 
the spinous processes of the tender vertebrae produces consider- 
able pain, while firm pressure may be borne without flinching. 
This shows its neuralgic character. 

Now, from what I have said you will infer that the causes of 

spinal irritation act either centrically or ec- 
trkaction entnc and eccen " centrically. In the former case a mechanical 

injury is done to some portion of the vertebral 
column. The shock is felt by the spinal nerves, and the muscles 



822 



THE DISEASES OF WOMEN, 



participate more or less in the painful result. In the eccentric- 
variety, however, the cause is more remotely applied. The irri- 
tant is at work at the incident nerves in their distribution to some 
muscle or organ, and, in a reflex way, the spinal center may be- 
come implicated even to the extent of producing absolute organic 
disease of the medulla, or of its enveloping membranes. The pain 
and trouble may become localized, but the irritation caused in 
these nerves is more apt to be reflected from the cord again to some 
particular organ or apparatus, as, for example, to the stomach or the 
bowels, to the bronchi and the lungs, to the heart, the head, or 
the liver. 

It is in this manner that utero-meningeal disorders originate 
and are perpetuated. There are undoubtedly many cases of 
spinal irritation that are in no way connected 
utfrfnTdbe2e ion and with uterine disease. And there are other 
cases in which, for sexual reasons, and on 
account of the perturbing influence of the menstrual molimen, or 
of maternal contingencies, the womb becomes indirectly and sec- 
ondarily implicated. But there are other cases also in which the 
uterus has been the prime factor in this morbid process ; cases in 
which the spinal nerves and the medulla itself have become de- 
ranged and diseased in consequence of some pre-existing uterine 
lesion. For this reason there are few confirmed examples of 
" irritable uterus," in which these two affections do not co-exist. 

Moreover, most of the fugitive, peculiar, inexplicable local 
pains, burning and suffering that are incident to confirmed dis- 
eases and deviations of the womb, arise from 

Reflex symptoms. . ... . 

uterine irritation which is conveyed by the 
sensitive nerve filaments to the cord and then reflected to these 
different points. It is thus that the infra-mammary pain is pro- 
duced. You remember that Dr. Simpson said this pain was as 
characteristic of uterine disease as the pain in the point of the 
shoulder is of hepatic disorder. We may refer the occipital 
headache of menstruation to a similar cause. The point which 
I wish to make is this, that the continued application of this irri- 
tant, brought from the suffering part to the sentient center, in the 
person of delicate, nervous women, is almost certain to cause a 
greater or less degree of spinal irritation. 

And what is true of the uterus is also true of the ovaries. The 



SPINAL IRKITATIOX. 823 

most troublesome cases of spinal irritation that I have ever treated 
originated in ovaralgia. The contingencies that 

From ovarian implication. . , , , 

beset ovulation even when the periods are regu- 
lar ; that may derange the innervation of these organs at puberty 
and the climacteric ; that may result from intemperate coitus and 
similar causes, are indirectly responsible for a large proportion of 
cases of what are termed spinal irritation. There may be cases in 
which the converse is true, and wherein the ovarian disease is sec- 
ondary upon the spinal lesion. Indeed, it is sometimes extremely 
difficult to decide between the cause and its effect, and to say 
positively whether the ovarian lesion is idiopathic, or vice 
versa. 

As a rule, however, I think you will find that the other coinci- 
dent disorders which sometimes attend upon spinal irritation are 

almost always secondary. Such are the dis- 

Secondary diseases. . . _ 

eases ot the respiratory system. It is seldom 
that aphonia, spasm of the glottis, dyspnoea,' or a violent nervous 
cough, in these cases is not directly referable to the spinal lesion. 
So also of functional troubles of the heart, and of the digestive 
system. We look to the spinal center for their cause, and hope 
to relieve them by its cure or removal. 

Diagnosis — Providing it has been caused by direct injury, and 
is therefore traumatic, the diagnosis of spinal irritation is not very 

difficult. This is true, no matter how long a 

In post-traumatic cases. . . 

period may have elapsed since the injury was 
sustained. It holds in Mrs. M.'s case, for example, although 
thirty-nine years have passed since the date of the accident. For 
this reason you should take especial pains to enquire whether 
such a patient has ever fallen, or received a blow upon any part 
of her back. It is possible that so long a time has elansed since 
the accident occurred, or that the mischief itself was attended by 
so little pain and immediate illness, that it may have been for- 
gotten. She may have tumbled down stairs, fallen upon the ice, 
from her horse while riding, or from a chair upon which she was 
about to sit, and hurt her back long ago, but because she thought 
it a trivial affair at the time, may forget to mention the circum- 
stance unless you enquire for it. 

Or it may happen that on account of mechanical injury to the 
coccyx during labor, a similar train of symptoms may have 



824 THE DISEASES OF WOMEN. 

been induced. In a word, whenever you can refer the lesion to 
a traumatic injury, however complicated the 

May arise from coccyodynia. . . , -. 

attendant symptoms, or trivial and remote the 
date of the accident, the original idiopathic disease will not be 
difficult of recognition. 

But, under different circumstances, the case is very different. 
When neither the patient nor her friends can recall such a misfor- 
tune, and there is no reason to believe that any 
di£™si!, lties in the way ° f portion of the vertebral column has ever been 
directly injured, it will not be so easy to decide 
the question. The tenderness of some portion of the spine upon 
contact and pressure, more particularly if it is constant, or habitual 
in certain positions of the body, is quite characteristic. If this 
tenderness is aggravated by the return or interruption of the 
menses, by coitus, by emotional states, or by sudden displace- 
ments of the womb, there is manifest spinal irritation of a reflex 
nature. Sometimes this exacerbation of pain and super-sensitive- 
ness in the spine alternates with the sexual infirmity or excitement, 
and this fact will help you to differentiate it properly. In very 
rare cases there is a cutaneous anaesthesia, which is allied to the 
pseudo-narcotism of hysteria, and which is almost invariably due 
to uterine or ovarian disease. 

Spinal irritation should not, and need not be confounded with 
inflammation of the spinal cord or of its membranes. Its advent 
is not characterized by a chill, rigors or fever. 
no™! n thtcorT^c f : amma ~ Tlie P ain is circumscribed in extent, erratic in 
character, and, in general, is worse upon slight, 
than upon steady or firm pressure. There is less dread of motion, 
and, unless in case of traumatic myalgia, more ability to move 
about than in real meningitis and myelitis. In the adult, menin- 
gitis is almost always either traumatic or epidemic. If paralysis 
occurs in spinal irritation, it is self-limited and not permanent, as 
it is apt to be in consequence of inflammation with serous effusion 
into the spinal canal. 

This disease may be distinguished from true neuralgia by the 
diffuseness of the pain which does not follow the track of any 
nerve or nerves, but is characterized, so far as it extends, by a 
general cutaneous tenderness. The reflex irritability is exagger- 
ated, and sometimes intensely so. Spinal irritation bears a pretty 



SPINAL IRRITATION. #25 

eiose resemblance to neuralgia, however, in such cases as we have 
had under review this morning. For where the cervical vertebrae 
are injured, it presents many of the symptoms of cervico-brachial 
neuralgia. This is especially true in highly neurotic patients. 

Prognosis. — The prognosis will depend upon the location, 
nature, extent, severity, and duration of the spinal lesion, the age 
of the patient, her peculiar nervous impressibility, and the more 
or less serious derangement of the menstrual function. The dan- 
ger is not usually proportionate to the degree of suffering. Coin- 
cident disorders of respiration may be more grave in character 
than such as implicate digestion. The nervous symptoms are 
usually more alarming than serious, although it is possible that 
permanent paralysis of some of the voluntary muscles may fol- 
low. In some cases there is a form of hysterical mania that is 
quite unmanageable by the ordinary means, which is, however, 
likely to terminate of itself, providing too much is not done in the 
way of treatment. 

In case the irritation has been caused and maintained by a 
lesion of the generative organs, the possibility of cure will depend 
upon one of two things ; (1), the curability of the uterine or of 
the ovarian disease, whatever it may be, and (2), our ability to 
remove such sequelae as may remain when the antecedent affection 
has been remedied. Patients with spinal irritation frequently 
recover when the climacteric has passed. 

Treatment. — These are the patients who travel from one physi- 
cian to another. By the time you have them fairly in hand you 
will find that they are experienced itinerants. 

Itinerant patients. tit r> 

Iheyhave run the whole gamut ot the profes- 
sional possibilities, and, at last, are persuaded that, if you can not 
benefit them, nobody can. But, in a short time, unless you are very 
skillful in treating them, or successful in satisfying them that you 
do really understand the case and expect to cure them, they will 
be adrift again. 

If from any cause the symptoms of spinal irritation are devel- 
oped, as they were in this case, at a time when the menstrual 
function is about to be established, or when the 

^Guarci the menstrual func- c ] mn g es ^.^ are i nc i(l en t to puberty have 

already begun, you should take the greatest 
possible care to do nothing that can interrupt this process, or pre- 



S26 THE DISEASES OF WOMEN. 

vent its accomplishment. Your aim should be to remove all obsta- 
cles thereto, and so to regulate the operations of the nervous 
system as to favor and assist Nature in her critical effort. For it 
is manifest that if puberty is not delayed, and the catamenia 
appear as they should, the nervous and other functions can not 
be in a very bad condition. 

If the symptoms of spinal irritation appear when the menses. 

have been suppressed, as after pregnancy, lying-in and lactation, 

or from amenorrhoea, a similar indication will 

In amenorrhoea and at ex ist. Alld if they COHie Oil with the dimaC- 

the climacteric. J 

teric period, you will bear in mind what I said 
in my last lecture concerning their treatment under these circum- 
stances. 

Incidentally, whatever disease may drain the patient's strength 

or exhaust her energies, should be remedied as speedily as possible. 

A quarter of a century ago, when this poor 

Remove any dangerous woman suffered for two consecutive months 

condition. 

with uterine haemorrhage that was due to the 
presence of a hydatid mass in utero, there may have been some 
excuse for a lack of promptness in emptying the womb and stop- 
ping the flow. For the sponge-tent was unknown, Bnd physicians 
had almost as great a dread of manipulating or operating upon the 
uterine cervix as surgeons had of opening the cavity of the peri- 
toneum. But now such a haemorrhage should not be permitted. 
The neck of the womb could be readily dilated and the foreign 
body removed. 

In order to counteract the peculiar impressibility of your female 
patients, and thereby to put them in a condition that is favorable 

to the cure of spinal irritation, you will need 

Tact and sympathy. . 

to exercise a great deal ol tact and a large 
measure of sympathy and discretion. Rough treatment may 
sometimes be tolerated in other cases (although it is inexcusable) r 
but in this disease it will not be borne. The patient's perceptions 
are too acute, and she is too susceptible and sensitive to be treated 
in such a way. Your manner should be kindly, your words fitly 
chosen, your tone sympathizing, and your faith in her desire to 
get well, and not to deceive you, unbounded. If you are fully 
impressed with the tenderness and delicacy of her organization on 
the one hand, and with the irritable, excitable and wretched state 



SPINAL IRRITATION. 827 

of her nervous system on the other, you will never be guilty of 
adopting such a mode of treatment as must necessarily make her 
worse instead of better. 

If the attack originated in a strain, shock, blow, or fall, 
although years may have passed since the injury was sustained, 

arnica, rhus tox., calendula, or the hypericum 
s P Fn°a r i hljury^ 015 ° f the P er f-> w iH be indicated. I have s^reat confi- 
dence in the latter remedy given internally and 
applied locally at the same time for traumatic injuries of the spine 
and its membranes. The other medicines named may also be used 
both constitutionally and externally. 

For rheumatic and neuralgic complications the most prominent 
remedy in many cases is macrotin, after which there are rhus tox., 

bryonia, spigelia, belladonna, atropine, aconite, 
raigfc symptoms and neu ~ veratrum alb., veratrum vir., colocynth, lachesis, 

caulophyllum, nux vomica, colchicum, and gel- 
seminum, with the leading indications for which you are already 
familiar. 

Whatever uterine or ovarian diseases have been sufficient to cause 
or to complicate the spinal lesion, should first be treated as if they 

existed separately and idiopathically. But 
rian°s ^m t l oms ne and ° va " wnen these are removed or cured, such spinal 

and nervous sequelae as remain may be treated 
more directly and specifically. Uterine deviations, cervicitis, 
hypertrophy, and ulceration of the cervix uteri and hysteralgia 
are the more frequent of these affections, which have the first 
claim on our professional attention. To these may be added sub- 
acute and chronic ovaritis, and ovarian neuralgia. 

The respiratory, digestive, hepatic and general nervous derange- 
ments which are secondary upon the spinal trouble, will usually 

yield to treatment that is addressed to the cure 

For contingent disorders. n i t • 

oi the lesion upon which they are dependent 
for a cause. The symptoms must be carefully studied and the 
remedy affiliated properly, else there will be but a poor prospect 
of success. 

Local adjuvants are sometimes of the greatest possiole service 
in the treatment of this troublesome com- 

Local treatment. 

plaint. They are not only grateful and useful 
on account of the relief which they afford, but do really assist in 



82S THE DISEASES OF WOMEN. 

the cure. I suppose that their modus operandi is by excluding 
the presence and pressure of the atmosphere upon the tender sur- 
face along the spine. My own preference for these local expedi- 
ents has been based upon the following indications : 

If the muscles of the back or of the neck are cramped and very 

painful, I direct that the surface shall be thoroughly anointed 

with camphorated oil. This may be gently 

For painful cramping, etc. . tit 

rubbed over the painlul part, or applied by 
means of flannel compresses. The oil soothes and softens, and the 
camphor relaxes the muscular spasm. Bathing with spirits of 
camphor is less efficacious, because both the camphor and the 
alcohol evaporate so quickly. 

Where there is less pain and more diffuse tenderness, it gives 
great relief to coat the surface with the oleaginous collodion. 

If the disease has resulted from a mechanical cause, you will 

not forget the local use of arnica, hypericum, calendula and 

hamamelis. I believe these topical applications 

Topical expedients. .',.-.. . 

have the best effect, m this disease especially, 
when they are diluted in and applied by means of hot, instead of 
cool or cold water. In mild cases, a porous plaster will sometimes 
afford relief. Dry cupping, and the exhaustion of the air by 
means of cups to which the air-pump is attached, affords a useful 
expedient in some cases. But sinapisms, blisters, pustulation by 
croton oil or tartar emetic, and issues and setons of all kinds are 
harmful and unnecessary. 

The spine should be insulated as it were, by a layer of cotton 
batting, or of oiled silk, wwn next the skin. The cotton may be 
sewed into the clothing and kept constantly 
applied, day and night. It should extend from 
the neck throughout the whole length of the back. In many 
cases, more particularly in those who are predisposed to rheu- 
matism, the patient should wear a silk vest, or under- wrapper, to 
protect her from sudden vicissitudes of the weather, and from 
electrical changes. 

Sponging the back from above downwards with warm, or hot 
water, may help to remove the extreme sensitiveness of the integu- 
ment. It should be done very carefully how- 

Available expedients. -, . n •-> n i l ■ • ' • 

ever, and, if possible, by a person who is m 
sympathy with the patient, and towards whom she has no feeling 



SPINAL IRRITATION. 829 

of antagonism. In chronic cases, with marked debility, salt- 
water spongings along the spine are sometimes very beneficial. 
In certain cases, the shower-bath, electricity, and animal magnet- 
ism may also be useful. They should, however, be administered 
with care and discrimination, else they may only serve to increase 
the difficulty. The electrical bath answers as an available tonic, 
when the general strength is very much reduced, and the patient's 
nervous system needs a ready means of support of some kind. 

A recent writer says: " There is one special phase, however, 

of spinal irritation which is very amenable to a direct treatment, 

viz., cutaneous and mucous tenderness. When- 

Faradization. . , . . , . . 

ever the 'ny persist he tic part is within reach, so 
that we can apply Faradization, we can almost certainly eradi- 
cate the morbid sensibility very quickly. The secondary current 
of an electro-magnetic or volta-electric induction apparatus is to 
be employed; the conductors should be of cliw metal, and the 
negative one, which is to be applied to the painful surface, should 
be in the form of the wire-brush. The positive pole is to be 
placed on some indifferent spot, and the negative is to be stroked 
briskly backward or forward over the sensitive skin, a pretty 
strong current being employed. The process is painful, so much 
so that it will often be advisable, with delicate patients, either to 
administer chloroform or to inject morphia subcutaneously before 
the Faradization. A very few daily sittings of four or five min- 
utes length, will generally remove the morbid tenderness com- 
pletely. When the tender part is within one of the cavities, as 
the rectum, bladder, vagina, or pharynx, we must of course use a 
solid negative conductor of appropriate form, and must content 
ourselves with applying it to one point after another of the sensi- 
tive surface." 

Here are the notes of a case of " back-ache" which applied for 
treatment a few days ago. 

Case. — Mrs. , aged 27, living in Wisconsin, is the mother 

of two children, the youngest of which is eighteen months old. 
From her marriage at eighteen, until the birth of her child in the 
twenty-first year, she was subject to uterine catarrh, and was in 
wretched health in consequence. But after the baby was born she 
recovered entirely, and was well until the birth of her second child, 
two years later. " Her second labor, which was more tedious and 
difficult than the first, was natural, except that the placenta was 



830 THE DISEASES OF WOMEN. 

so adherent that the doctor had great difficulty in removing it. For 
four years she has not seen a well day. Her symptoms are a con- 
stant pain in the back which unnerves her, keeps her off her feet, 
and " drags the very life out of her." The stomach is upset, the 
emotion are demoralized. She is bankrupt physically, cannot sleep, 
eat or think as she should, and, more than all has been through 
the hands of five doctors. 

A local examination disclosed a decided prolapse of the womb 
and the vagina, and a laceration of the perineum as far as the 
sphincter and, she had never been examined but once before, when, 
she says she was almost killed by an instrument that was forced 
into the vagina ! It really was unnecessary to use a speculum, for 
with the perineum laid open and the vagina almost everted, the 
uterus fell readily into view by the mere separation of the labia. 
It seems incredible that so many physicians could have prescribed 
for her without havinff made a local examination. But it is not 
strange that she should have had so many symptoms of dilapida- 
tion, and that her nervous system should be such a wreck, when 
the pelvic organs were in such a condition. 

PHYSOMETRA. 

Case. — May, 1864. Mrs. B , aged twenty-tour, of san- 

guineo-nervous temperament, has been married six years, and is 
the mother of two children. She was delivered of the youngest 
ot these, one year ago, — during the riots in the city of New York. 
She says she had a short and easy labor, after which she did well 
until the third day, when, the report having been circulated that 
the house in which she was living would be fired or destroyed, 
she was obliged to remove to another. The distance being only 
two squares, she insisted upon walking, and really accomplished 
the task, but under great mental excitement. The result was at 
first a partial, and after the fifth day, a complete suppression of 
the lochia. 

In a short time her present symptoms began to trouble her, 
and they have continued during the whole year. There is a 
circumscribed enlargement of the abdomen, situated in the mesian 
line, and extending from the pubis towards the umbilicus. This 
tumor increases in size so that at times she is quite as large, and 
looks as if she were seven months advanced in pregnancy. At 
other times, and especially after a good night's rest, its size is 
greatly reduced. Exercise and excitement increase its volume. 

When she reclines the tumor gravitates or rolls toward the side 
upon which she is lying, but without any change in its form, and 



PHYSOMETRA. 83 

without borborygmus. It is still circumscribed, and always tym- 
panitic. The neighboring parts yield their normal sounds on per- 
cussion. The only pain she has had is a species of soreness from 
outward pressure, or distension. She is at times sensible of hav- 
ing had a discharge of flatus per vaginam, but has never had 
eructations. 

Sometimes, she says, this tumor or swelling feels as if it were 
rising into the stomach, and again into the throat. Occasionally 
she has headache and a flushed face, especially in the afternoon. 
She is a very intelligent woman, and is confident that she has 
never before had any uterine difficulties. The urinary function 
is normal, and in every other respect she is healthy. She was 
unable to nurse her child. 

It may be a long time before you will see so good an illustra- 
tion of this curious affection as we have here this morning. 
Indeed, owing to its rarity, many physicians of 

The tumor. . . 

large experience have never seen a case of this 
kind. If you observe the physical characters of this phantom 
tumor, } r ou will note that its outline is as well-defined as that of 
an ovarian cyst. It may be very hard, or it may yield to pressure, 
like a soft foot-ball, and is tympanitic on percussion. You hear 
this sound distinctly. The tumor changes its position when she 
turns upon either side, and rolls about to a limited degree, but 
there is no bulging in the lumbar region, and no flattening of the 
anterior surface of the tumor when she lies upon her back, as in 
ascites. 

Physometra, or the collection of flatus in the womb, is almost 
always, directly or indirectly, related to gestation, or to the par- 
turient state. Sometimes, however, it occurs during menstrua- 
tion, and again in consequence of the presence of uterine hyda- 
tids, moles, polypi, and such intra-uterine growths as are liable to 
become decomposed, either before or after their detachment. 
Whether as cause or effect, hysterical symptoms are always pres- 
ent in these cases, as in other forms of tympanites to which women 
are more especially, but not exclusively liable. The lochia, the 
milk, and the menses, are suppressed. Sometimes, however, the 
breasts fill as they do in pregnancy. The nervous symptoms 
predominate. 

The most commonly accepted cause of this singular infirmity is 
the retention and decomposition in utero of the foetus, of some 



832 THE DISEASES OF WOMEN. 

portion of the secundines after delivery ; or similar changes in 
fragments of intra-uterine growths which have 
failed to be expelled by nature, or removed 
by the physician. The gas that is formed in consequence of 
the decomposition of organic matters is fetid, 
reSfneT 1 " 05 ^ " ° f ma " er ancl is incarcerated in the cavity of the womb 
by the spasmodic closure of the cervical outlet. 
It is possible that similar changes may take place in the men- 
strual excretion, and also in the membrane (decidua menstrualis), 
which is sometimes exfoliated during that process, and which if it 
is retained by closure of the uterine neck, might also undergo 
chemical decomposition. Occasionally the arrest of the lochia 
results in the development of this form of uterine tumor. This 
cause is more powerful when conjoined, as in this case, with 
apprehension and anxiety, as well as with premature exposure and 
excess of fatigue almost immediately after the birth of the child. 
Some writers ascribe the uterine enlargement in physometra to 
a collection of atmospheric air in the womb, which is either drawn 
into that organ by a species of suction, or passes 
^suction of air into the i n ^ ft w h en the os uteri is open and other mat- 
ters have so escaped as to leave a vacuum, into 
which the air may rush until it is filled. Dr. Harley cites a case 
of alternate admission into, and expulsion of air from the vagina.* 
Something of this kind, it is thought, may, in very exceptional 
cases, take place in the womb. 

But there are instances in which, unless we ascribe it to mental 

excitement, it is quite impossible to detect any cause for this 

tumor. Acting upon a hysterical predisposi- 

Mental causes. . 

tion, there is no valid reason why an excess of 
flatus might not be as readily secreted or formed within the ute- 
rus, as it obviously may in the bowel or the stomach from a simi- 
lar cause. And nothing is more common than hysterical tympan- 
ites from emotional causes in this class of patients. But I will 
not detain you with further remarks on this subject. 

The diagnosis is much easier than it was a few years ago. You 
have only to put the patient under the influ- 
ence of chloroform or ether, and the differenti- 
ation of this species of tumor will declare itself. For if it is a case 

transactions of the Obstetrical Society of London, Vol. IV., page 173. 



PIIYSOMETRA. 833 

of physomctra, or indeed of a phantom tumor of any kind, the 
enlargement will disappear altogether. You can satisfy your- 
selves that the accumulation has been in the womb and not in the 
bowel, by passing a small can u la, or a male cathether, through 
the os uteri. Then, by placing the outer extremity of the in- 
strument under water you can evacuate the tumor through it, 
and be assured of the escape of gas therefrom. I tried this ex- 
periment on our patient yesterday, and, therefore, am confident 
in my diagnosis. 

The treatment consists in removing any decayed substances that 
may have remained in utero ; and in preventing their retention in 
the future. The cervix may be kept open for 
the free discharge of such matters, and of the 
gas also, by the use of the sponge-tent and the ordinary means 
of dilatation. If the case is a recent one, and the lochia have been 
suppressed, they should, if possible, be restored. If the patient 
is hysterical, this tendency should be counteracted by appropriate 
medical, moral and hygienic means. If the excessive size of the 
tumor worries her, it may be evacuated a few times for her com- 
fort during the day.* 

In case the uterine tympanitis depends upon the retention and 
decomposition of water within the womb [hy- 
Tappins the uterus. drometv ^ G f blood within the same cavity 
[hsematometra], or of pus [pyometra], the fluid or its debris 
must be evacuated either by paracentesis, or by the forcible dila- 
tation of the cervix uteri. But, you should remember that the 
mere expansion ot the neck of the womb and the escape of the 
decomposing fluid is not all that would be required. For putrid 
or purulent changes would only be hastened by insuring its contact 
with the air ; and hence it is quite as necessary to cleanse the 
uterine cavity of its poisonous materials as it is to furnish an out- 
let for them. 

Although it is the fashion just now to carbolize the intra- 
uterine injections when they are necessary, both 
tions ra " UterinelnJeC " in the Puerperal and the non-puerperal state, 
my own preference is for a solution of the 
chloride of lime, which is a better disinfectant, and quite aa good 
an anti-septic. As you have seen us use it in our puerperal 

* In four weeks this woman was well and menstruating' normally. 






834 THE DISEASES OF WOMEN. 

wards, you may add a tablespoonful of the officinal solution of 
the chloride of lime, which you can obtain from the druggist, 
to a quart of warm water that already contains a tablespoonful 
each ot glycerine and calendula. If the odor is extremely offen- 
sive, the proportion of the lime-water and the glycerine may he 
doubled. 

In a very interesting case of physometra that was brought to 

me by Dr. A. J. Howe, of California, there was 

a marked increase in the gaseous accumulation 

whenever the patient had an excess of mental work or worry, 

and her greatest relief was obtained by letting the mind rest, 

more especially at the time of the monthly period. 



Part Ninth. 



THE SURGICAL DISEASES. 



LECTURE LI. 

UTERINE SURGERY VERSUS UTERINE THERAPEUTICS. 

Uterine surgery vs. Uterine therapeutics. The gynaecological chair or table. Vagm» 
ismus. 

The line of demarcation between sanity and insanity, animal 
and vegetable life, and this world and the next, is not more indefi- 
nite than that which separates surgical from therapeutical indica- 
tions in the cure of many diseases. This is especially true of the 
treatment of the Diseases of Women. What reliance shall be 
placed on manual operations, and what upon medicinal influences 
in curing them, is an unsettled question. There are those who 
insist that, in this specialty, surgery is almost omnipotent, and^er 
contra those also who claim that constitutional remedies alone are 
adequate to the end in view. 

The attentive student of gynaecology is aware that within the 

last quarter of a century, Uterine Surgery has developed from a 

rudimentary to an almost perfect branch of 

Value of uterine surgery. -..,. T , n . , -. • -i i 

medical science. It has furnished us with the 
most approved and available means of diagnosis, and with a mul- 
titude of resources for the relief and cure of certain diseases that 
w^ere the opprobrium of medicine. It has fulfilled old indications 
with new and approved instruments, reconstructed the special 
pathology of sexual disease, and re-organized our aims and pur- 
poses and expedients in such a manner as to add very greatly to 
the comfort and welfare of woman. It has added another chair 
to the medical curriculum, augmented and improved our litera- 
ture, and developed a new and most useful specialty, which al- 
ready is more popular than any other, and which, at no distant 
day, bids fair to engross the attention and to appropriate to itself 
a large share of the medical talent of this and other countries. 

It was a very natural consequence of this rapid growth in the 
professional and popular favor that the claims set up for Surgery^ 

835 



836 THE DISEASES OF WOMEN. 

as applied to the treatment of the Diseases of Women, should 
he somewhat exclusive and extravagant. Dr. 

Extravagant claims. . 

Joennet irames his formula that ulceration and 
induration of the uterine cervix lie at the bottom of nearly all the 
diseases peculiar to the sex. Local cauterization will frequently 
remove these conditions — which he has been shrewd enough to 
confound in his writings, and therefore escharotics are specific. 
The generalization is the bait, the manipulation attracts, and the 
parade causes a premium to be placed on the operation. Forth- 
with his experiments and deductions are the text and the theory 
for an indiscriminate local treatment designed alike for all kinds 
of uterine affections and utero-visceral derangements. 

Sir Jas. Simpson incised the cervix as a remedy for obstructive 
dysmenorrhcea. Sims adapted his scissors as a uterotome, and 

improved upon the operation. The same oper- 

Illustrations. . 

ation was soon recommended tor the cure ot 
sterility, and retro-flexion of the uterus. Then it was applied to 
the relief of the intractable uterine haemorrhage, and as a means 
of exploration and of facilitating excision in uterine fibroids. 
Now, in multitudes of cases, the uterine cervix is slit open, with 
every possible kind of result. The operation is a favorite one, for 
blood is shed, and there is some cutting in the dark, — which is 
always attractive in ratio with the risks that are taken. 

The various modifications and varied uses of the uterine specu- 
lum, the sound, the probe, the sponge and other tents, the explor- 
ing needle, the endoscope, and physical exploration by palpation, 
auscultation and percussion, have engaged the almost exclusive 
attention and confidence of uterine pathologists. Armed with 
these instruments, and aufait in using them for purposes of diag- 
nosis and of treatment, it is not at all strange that they have come 
to place an almost exclusive reliance upon them, and that the 

claims of a coincident and conservative thera- 
tiSi? ri r e nore e d apeuticsprac "P eu ^ cs should, have been either overlooked or 

disregarded. They esteem the proposal to 
unite a course of medical with the surgical treatment of uterine 
ulceration, cervicitis, or endo-metritis, for example, as altogether 
superfluous — a species of superf (station. When their resources 
are sufficient, and their work is substantially clone, why propose 
to add anything, or. to substitute it with what is less attractive, 



UTERINE SURGERY VS. UTERINE THERAPEUTICS. 837 

ilashy, seductive and sensational ? For, with all our boasting, it 
remains that, in this class of diseases, the operation of the best 
chosen internal remedies, is not and cannot be instantaneous. 
The relief they bring in chronic uterine and ovarian affections 
especially, comes only "after many days.*' They do their work 
quietly, and without any of the ad captandum eclat of a surgical 
exploit, or a sanguinary battle from the possible effects of which 
the patient may never recover. It is an axiom in midwifery that, 
whether natural or induced, the most rapid cases of labor are not 
the safest. In uterine surgery the risks are in ratio with the bold- 
ness and dispatch of the operator, which qualities are almost insep- 
arable from its employment. 

It is equally obvious that the disproportionate development of 
uterine surgery is due to causes that can be explained, and which 
are avoidable. Let me call your attention to a few of them. 

1. The groiving scepticism in the minds of specialists concerning 
the effects and efficacy of internal medication. Providing he is edu- 
cated and thoughtful, the pursuit of a medi- 
JcESfclr respecting cal specialty invariably inclines the physician 
to place less reliance, than does the general 
practitioner, upon constitutional treatment as a means of cure. 
The oculist and the aurist are not given to the common weakness 
of dosing their patients. Those who treat the diseases of the 
respiratory organs exclusively and most skillfully have more con- 
fidence in hygienic measures than in medicine. With every class 
of specialists, the higher the grade of their qualification, and 
the broader their field of observation, the lower their estimate 
of general treatment. For these men are sufficiently educated to 
discriminate and to differentiate. Their knowledge of physiology 
and of pathology assures them that, not only does every part 
suffer with the sick organ, or member, but that for the same rea- 
son, whatever lowers the general vitality will lessen the chances 
of recovery. 

Uterine pathologists necessarily reach a similar conclusion. Un- 
less their ideas of medicine, and of its capacity to cure, or to 

injure, are stereotyped and more or less anti- 
Abandonment of old ideas- 

quated, they gradually abandon the old thera- 
peutics, and learn to place an increased trust in modern surgery, 
with its topical expedients and its manifold resources. The 



838 THE DISEASES OF WOMEN. 

cultivated gynaecologist of our day would as soon think of 
resorting to general blood-letting in hysteria, as to the use 
of emmenagogues in amenorrhcea. When Dr. Thomas coun- 
sels that the bowels shall be left in a constipated condition in 
endo-metritis, it implies not only that he has a clear idea of the 
indications that are presented for the cure of that disease, but 
also that, in proscribing cathartics, he is interested in removing 
a fertile source of mischief in uterine complaints.* 

Without pausing to elaborate this idea, it must suffice to call 
your .attention to the fact that the cultivation and practice of this 
specialty, as of every other, has had a two-fold result ; (1) it has 
stimulated a development of a special branch of surgery : and 
(2) it has impaired the general confidence in wholesale medica- 
tion for the cure of limited functional and organic disease. 

2. The natural preference which physicians, and their patients 

also, have for operative interference instead of internal treatment, 

whenever the former is possible. As compared 

Surgery more popular. -,1,1 ,-t l • • i i j 

with the surgeon, the physician labors at a 
great disadvantage. And the reward of his skill and patience 
are often disproportionate to the time and care bestowed 
on the cure of intricate and dangerous diseases. Although 
they may be equally skillful, each in his own department, my friend 
the professor of surgery will most likely gain more eclat by 
cutting off a limb, or excising a tumor, than my colleague in the 
chair of theory and practice will from curing a case of cerebro- 
spinal meningitis, Bright's disease, or of angina pectoris. All of 
which implies that we involuntarily place a premium on the 
manual operation, while it is such an ordinary affair for the phy- 
sician to tide his patient over his difficulties in a more quiet way, 
that but little relative stir is made concerning it. 

We do not criticize this propensity, although it has sometimes led 
to deplorable results. For it is impossible that such a large number 

of earnest and able workers should devote 
t Ie e n r e Te U cted S . oughtnot their lives to the study and practice of uterine 

surgery without bringing it to a certain de- 
gree of perfection. And the more popular, the larger the field of 
experience, the greater the number of those who are competent to 

* A Practical Treatise on the Diseases of Women ; by T. Gaillard Thomas, M. D„ 
etc., etc., Philadelphia, 1872, page 227. 



UlERINE SURGERY VS. UTERINE THERAPEUTICS. #39 

practice it, the older the study, the more thorough its literature, 
the greater, better and more lasting will be the benefits conferred 
by it upon the profession and upon the race. 

But an evident result of this bias toward surgery is a neglect 

to cultivate and develop the curative sphere and relation of our 

remedies to the class of diseases under con- 

Studythem. . . . 

sideration. We study the special therapeu- 
tics of other ailments most carefully. It is not permissible 
to transfer them to the domain of a different branch of the 
healing art. Every species of clinical enquiry and analysis 
is entered upon and prosecuted with a view to the proper selec- 
tion of the remedy or remedies. The symptoms are balanced, 
the signs are translated into a familiar language, everything is 
made available, medically, to effect a cure through the opera- 
tion of the vital forces. 

If we could point to therapeutical results in gynaecology which 
compare with those of uterine surgery, results which were as 
carefully obtained, as accurate and trustworthy 
in every particular, as critically analyzed and 
as readily available, our usefulness would be doubled, and the 
little world in which we now work as specialists would consist 
of two hemispheres instead of one. 

3. The comparatively limited opportunities and skill of those who 
have labored especially to develop uterine therapeutics. — The allure- 
ments to surgery, and its very general prac- 
spSfaulr 1 ^ 65 ° f the tice among physicians and specialists, diminish- 
es the number of those who are laboring 
to define and determine the special therapeutics of uterine and 
kindred diseases. And the tendency of patients who are thus 
afflicted to estimate what is done for their relief and cure by the 
scale of suffering and risk at the hands of the doctor, lessens the 
number of those who are willing to trust and to wait for the 
results which might often be obtained by fitly-chosen remedies. 
Acid <o this that those of our physicians who are most competent 
to do this work are usually engaged in general practice, and it is 
leally no reflection upon their popularity, or their ability, to say 
that one reason why uterine surgery has outstripped uterine thera- 
peutics in the race, is because the opportunities and skill of those 
who practice the latter are comparatively limited. 



840 THE DISEASES OF WOMEN. 

4. The bias towards harsh and harmful remedies whenever inter- 
nal means are employed. — There is a current idea which holds that 

when the internal generative organs of the 

A great error. ° ° 

female are diseased, they require that stronger 
medicines should be given than in case of a similar disease 
which is seated in another organ or apparatus. This view 
is entertained by many who do not hesitate to acknowl- 
edge the wonderful delicacy of the nervous and vascular sympa- 
thies of the uterus and its appendages. And yet they insist that it 
is sometimes necessary to medicate these patients very thoroughly 
before any benefit can be derived from remedies that have been 
taken internally. 

The consequence is that, becoming disgusted with such treat- 
ment, or afraid of it, these patients put themselves in the care of 
such doctors as will not dose them at all, but who will rely exclu- 
sively upon other means of relief. 

5. The theory that constitutional treatment is destined altogether 
to supersede surgery in the management of these sexual disorders. — 

Surgery is the complement of therapeutics as 

Surgery and therapeutics. . 

one hand is oi the other, or the right eye ot 
its fellow. To assume that it is possible in all respects to 
substitute, or to supersede the necessity for either of them, 
would be like limiting the obstetrician to the use of but one 
hand, or the microscopist to that of one eye exclusively, and 
denying them the privilege of using the other under all circum- 
stances. The practical accoucheur is ambidextrous. And, if the 
microscopist uses but one eye at a time he alternates them. Each 
has its own sphere and function, and they must share the duty 
that is to be performed ; for, although one may be preferable to 
the other, according to idiosyncrasy, habit, education or circum- 
stance, still it remains that this dual arrangement is a part, and 
an indispensable part, of our organization as individuals. 

The same is true of the curative relations of medicine and sur- 
gery. Both are requisite, each in its proper place, but which shall 

be the more prominent will depend upon the 

Both essential. ,. ... in. i n • j> ., -, 

peculiarities, habits and education ot the phy- 
sician, and also, as we have shown, upon a variety of circum- 
stances. To declare that either of them is superfluous, and to 
declaim against its employment, very naturally excites a pre- 



UTERINE SURGERY VS. UTERINE THERAPEUTICS. 841 

Judice against those who talk and act so unreasonably. It is a 
question of boundary lines merely, and since the whole field 
belongs to us, we can shift the fences from time to time and 
cultivate the crop of expedients that will prove to be most 
valuable and useful. 

To compensate for this lack of interest in medicine as applied 
to the treatment of the diseases of women, it will be necessary, 

1. To have a series of new provings, on women, which shall be made 
with the greatest possible care and discrimination. — The health of 
woman is beset by so many contingencies, and 
^7.1^^™°™™ she is subject to such crises as to render it 
very difficult to find one who, both in her- 
self and her surroundings, is suited to become a prover ; and 
the physicians who are really competent to superintend such a 
proving are perhaps equally rare. For, if such an index to the 
remedial relations of a drug shall be trustworthy, it implies that 
the physician who undertakes this labor is fully conversant with 
the whole range of uterine pathology ; that he has subjected his 
patient to the test of a most searching examination ; eliminated 
all the symptoms which • are naturally incident to menstruation, 
maternity, puberty, the climacteric, and also to her relations as 
wife and mother, to the church and to society, as well as to the 
distinctive susceptibilities that pertain to her sex, and which are 
so perplexing to all of us, and retained and classified only those 
symptoms which were unmistakably due to the action of the 
drug. 

The fact that this labor has not already been perfected, and that 
it is a task of no small magnitude, should not deter those who 
hope for better things of uterine therapeu- 
3n^eTr b krotiedge. to tics, from its faithful and persistent prosecu- 
tion. And I urge it upon you as members 
of this class to determine that you will add something to the com- 
mon stock of knowledge on this subject, something tangible and 
available, something that will be of service to those who are suf- 
fering, and which will prove that the pains you have taken in the 
study of special pathology and therapeutics have not been lost 
either to yourselves or to the profession at large. For, suppose 
that we had a full and complete proving of calearea carbonica, or 
of sepia, or of any other remedy, made with particular reference 



842 THE DISEASES OF WOMEN. 

to the female organism, and under the eye of a skillful specialist , 
there is no question that its influence fur good would outweigh 
that Avhich attaches to the invention of a new instrument, even 
if that instrument were as useful as the uterine sound. 

2. The most painstaking study of the differential diagnosis of the 
diseases of the female generative system. — This condition is requi- 
site not onlv because it concerns the skillful 

Study diagnosis. pi rr 

treatment of these affections, but- also because 
it bears a vital relation to gynaecological literature. If he 
keeps them to himself, the physician's short-comings are self- 
limited ; but if he publishes his blunders, he perpetuates their 
remembrance and ensures their repetition. Therefore, he should 
know what he has done, as well as what he is doing. 

With all due respect to those who have directly and indirectly 
contributed to our knowledge of materia medica, as it is applied 
to the diseases of women, it must be confessed 
that their labors would have been more fruit- 
ful of good if they had been better versed in uterine pathology 
and diagnosis. The clinical history of hundreds of cases that 
have been reported confirms the truth of this remark, and shows 
the need of culture in this direction. If every woman who 
takes a drug with a view to its physiological effects, were 
carefully examined, both physically and otherwise, before, 
during and after making the "proving;" if she could be 
removed from all the vicissitudes which are certain to derange 
her sexual sympathies and to upset her health, the symptoms 
evolved and collected would be a better criterion of the range of 
action of the drug than we can otherwise obtain. And if every 
physician were fully posted in the matter of diagnosticating the 
contingent symptoms, or deviations from perfect health, which 
occur in most women (which are necessarily transient and self- 
limited), and such as are really pathological and persistent, those 
which do not get well of themselves, and are not often cured, as 
well as those caused by emotional states, independently of our 
remedies, the value of our clinical record would be increased a 
thousand fold. 

This opens an avenue for usefulness and distinction ; for it is 
left for our school of practice to develop the medical side of this* 



THE GYNECOLOGICAL CHAIR. 



84a 



And pathogenesis. 



question. We deed such a chart of the remedial action, both 
pathogenetic and clinical, of medicines that are 
suited to the female organisms, as we do not at 
present possess. This is a sine qua non. It can not he obtained 
by the exclusive study of symptomatology after the old method, 
(1), because many of the resources of surgery are necessary as a 
means of determining whether or not the prover is in good health 
beforehand; (2), without these facilities, we 
could not know the variety, extent, nature or 
seat of the lesions present in a given case, whether they are func- 
tional or organic, and therefore our testimony concerning their 
cure could not be depended upon ; and (3), it must be true of the 
tissues which compose the generative intestine, as it is of other 
textures, that they have their proper pathological and therapeu- 
tical, as well as their anatomical, physiological and surgical his- 
tory and relations. 



And symptomatology. 




Fig. 134. Archer's gynaecological chair. 
THE GYNAECOLOGICAL CHAIR OR TABLE. 

Before we discuss the important operations in gynaecological 



8U 



THE DISEASES OE WOMEN. 



surgery, something more should be said of the chair, or table, 
upon which our patients are to be placed. After much experi- 
ence I think that, for an office chair upon which all the minor 
operations aud many others, including those tor laceration of 
the cervix uteri, and of the perineum, and for vesico- and recto- 
vaginal fistulse, the best is that rrade by George W. Archer, of 
Rochester, N. Y., and which is known as the Archer chair. (Ti°- 
124.) V "' 




Fig. 125. The same chair in position, with foot-arms and supports extended. 

The advantages of an adjustable chair which, if need be, can 
be converted into a table, are peculiar. With the class of pa- 
tients that consult us, we must be careful not to offend the most 
delicate instincts, or to frighten them beforehand by the display 
of instruments, or of surgical accessories of any kind. If a wo- 
man comes into your office and sees an operating table already 
equipped, she will very naturally forbear to tell her whole story, 
lest it may be necessary for her to climb upon that table. The 
very idea of a table is repulsive. If she is a stranger, she will 
run away from you, and will perhaps never come again, put, 
if she can first be seated in a comfortable arm-chair like this, 
(Fig. 125 ), and after a little lifted quietly into the desired position, 
as if she were in a dentist's chair, the whole thing can be easily 
managed, her sensibilities will not be shocked, and all will be 
done decently and in order. And, when you are through with 



THE GYNECOLOGICAL CHAIR. 



845 



the examination, the chair can be restored, and she will slip from 
it with a very different feeling from that with which she would 
dismount from a table. 

As you see, this chair can be so shifted as to fill a variety of 
indications. Fig. 126 shows an arrangement by which the patient 
can be brought into the knee-elbow, or into Sims' position very 
readily. In operating upon a lacerated perineum especially, the 
parts can be brought so near to the edge of the bed, and are so 
accessible that the whole operation is greatly facilitated. In this 
regard this chair is decidedly superior to that shown in Fig. 10, 
and also to Chad wick's table. (Fig. 11.) The "wrinkle" by 
which the outer edge of the seat can be lifted a few inches, and 
the chair inclined is sometimes of very great advantage. 




Fig lg6. The same, with the seat extension to permit of the knee-chest, and of Sims* 
position, and also the step or platform. 

When, however, we make these operations away from home, 
we must adapt ourselves to circumstances, and extemporize a 
suitable couch or table upon which the patient may rest. An 
extension table may be so shortened as to answer the purpose 
very well, or in lieu of it, you may use a common dining table, 
which is not too large, and which stands firmly upon its legs. In 
case you are frequently called upon to practice ovariotomy, peri- 
neorrhaphy, or any of the major operations in gynaecological 
surgery, it might be best to have such a table as you have seen 
used in my sub-clinic. 



846 THE DISEASES OF WOMEN. 



VAGINISMUS. 



Case. — Mrs. , aged 20, consulted me six months after her 

marriage for the relief of a forced continence which was extremely 
painful, and which made her morally wretched. The condition 
which she described very clearly, and which was confirmed by a 
local examination of the parts, was that of a spasm of the vulvo- 
vaginal orifice, which was induced by the slightest touch, and 
which spasm was sufficient to prevent the introduction even of 
my little finger into the vagina. The general health of my patient 
was good, and her menstruation normal, but she was very nervous 
and apprehensive, more especially on her husband's account. She 
was anxious to have the difficulty cured, not only because he was 
very kind to her, but also because she wished if possible to become 
a mother. 

The treatment adopted in this case consisted in the internal use 

of belladonna 3, three times 
daily, and in the gradual 
dilatation of the vagina, 
twice in each week. The 
dilatation was effected by 
an anal speculum, such as I 
hold in my hand (Fig. 127). 
fig. 127. Rectal speculum. ' This instrument was chosen 

because it was slender, could be easily anointed with cosmoline, 
and insinuated, and afterwards could be expanded gradually and 
held in position by the screw. She was a plucky little woman, 
and anaesthetics were not necessary. In six weeks she became 
pregnant. I afterwards delivered her with the forceps of a nine- 
pound boy, who is now the jolliest little fellow in my parish. 

Case. — Mrs. N , twenty-three years of age, married, has 

been out of health from the time her menses made their appear- 
ance, which was while she was at school, in her fourteenth year. 
She had all the usual symptoms of neuralgic or spasmodic dys- 
menorrhoRa with each monthly return The flow, alter the first 
day, was quite free, and it usually continued about a week. She 
was married at eighteen, five years ago. Soon after this the dys- 
menorrhcea ceased, and the "period" has been quite easy and 
natural until now. She has never borne any children, nor ever 
had a miscarriage. She menstruated as usual last week. A slight 
and temporary leucorrhcea sometimes succeeds the catamenial 
flow. 

She complains of great fatigue on slight exertion. This is 




VAGINISMUS. 847 

especially marked at intervals, which intervals have no knowi? 
relation to the monthly cycle. At other times she is as active 
and vigorous, and can walk or ride as far as any one almost. 
There is a good deal of pain and soreness along the superior por- 
tion of the spinal column, extending from the upper cervical to 
the last dorsal vertebra. Sitting, standing, and writing increase 
this pain and aching, which do not appear to be influenced by 
exposure to changes of weather. Sometimes she says there is a 
burning sensation along this portion of the spine, and again the 
burning is referred to the region of the left ovary. Occasionally 
the pain leaves the back and goes to that ovary. While it re- 
mains there, the left iliac region becomes tender to the touch, 
and she involuntarily retracts, or flexes the thigh upon the abdo- 
men. 

Her chief complaint is of pain and extreme tenderness at the 
ostium vaginse. This orifice is so sensitive, and the slightest con- 
tact is so very painful, as to render marital intercourse almost 
impossible. For more than four years she has consented to it 
only a very few times, and then has suffered an indescribable 
martyrdom. 

Physical examination finds the parts quite normal, excepting 
that just within the vaginal orifice, there is great tenderness to 
the touch, and the moment that the finger comes into contact 
with the marginal remains of the hymen, there is an immediate 
spasm of the muscular coat of the vagina, which causes extreme 
narrowness of that canal, and prevents its admission without con- 
siderable force. The superior portion of the vagina is flaccid and 
capacious enough. The uterus is in its proper place, and does 
not appear to be changed in any respect. The bladder and the 
rectum are healthy. 

This complaint is a very painful one, and one from which 
women sometimes suffer in silence for } r ears together without the 
courage to consult a physician for its relief. I believe that, in its 
milder forms, it is more frequent than is generally supposed. It 
may occur in the virgin, or in the case of those who are married, 
but not in those who have ever had a child or children. 

The symptoms are similar to those which our patient has de- 
tailed. There is almost always spinal tenderness, soreness, and 
lameness, which are generally located between 
the shoulders and along the cervical portion of 
the spine. Sometimes, however, it is lower down the spina] 
column, and is described as a weakness of the back and hips. 
The soreness or weakness is paroxysmal, and is aggravated by 



848 THE DISEASES OF WOMEN. 

exercise, but more especially by sexual excitement. In its recur- 
rence it is very apt to alternate with ovarian pain, burning and 
irritation. A hysterical cough, aphonia, headache, or a tendency 
to general spasms, are not unfrequent accompaniments of this 
spinal irritation. Spasmodic dysmenorrhcea and strangury often 
complicate the case, and cause additional suffering. (Exit the 
'patient.) 

But the peculiar and distinctive symptom of vaginismus is the 

hypersesthesia of the vulva and of the outer extremity of the 

vagina, which is so very sensitive that even the 

Local hjrperaesthesia. _ _ . 

slightest touch causes a spasm ot the sphincter 
vaginse, and a closure of that canal. The closure may also extend 
to the sphincter ani. The location and. extent of this sensitive sur- 
face varies in different subjects. In. virgins, it may be limited to 
the outer face of the hymen, which membrane, in these cases, is 
thicker and more firmly organized than usual. In those married 
women in whom the hymen has been ruptured, the tenderness is 
frequently most marked somewhere along the marginal remains 
and attachments of this membrane. The carunculse myrtiformes 
may be exquisitely sensitive. In many cases the most tender 
point is upon the side of, or near to the meatus urinarius. In 
others, it is about the orifice of the vulvo-vaginal gland, and 
sometimes at the fourchette. 

In this condition the contact of the finger, or even of a camel's 
hair brush, or of a feather, may cause the greatest agony, and 
perhaps throw the patient into convulsions. Coitus is impossible, 
and you can not introduce the smallest speculum without almost 
killing her ; indeed, in some cases that I have treated, the vaginal 
orifice was so closely and tightly constricted that I could not pass 
my little finger, or even a female catheter, into the vagina with- 
out exercising undue force. The sexual act being more or less 
completely performed, the suffering finally becomes so great that 
the parties are forced to desist, and most of these patients con- 
fess either that they have altogether relinquished the attempt and 
concluded to live apart, or, as they sometimes do, as brother and 
sister ; or that it is undertaken only at long intervals. Usually 
such women remain childless. It has happened, however, that 
even under these embarrassing circumstances, conception has 



VAGINISMUS. 849 

taken place, and gestation and parturition have cured the case 
spontaneously. 

If these symptoms continue for years, and the patient is sub- 
jected to all the mental worry that is their indirect consequence, 
and to the contingent diseases which such a 

Causes. _ . . 

state oi the nervous system is almost certain to 
induce, her general health will finally become impaired, and she 
will pass into a state of decline. She will become prematurely 
old, emaciated, dyspeptic, hypochondriacal, and a wretched " ner- 
vous wreck." The worst results may happen to her household 
and family. She is very apt to conclude, and may even be told 
by her physician, that she has an incurable disease of the womb. 
Her husband is likely to become estranged, and her married life 
to prove a disastrous failure. 

This disease is frequently complicated, either as cause or effect, 
with spasmodic dysmenorrhcea. Sometimes it arises from a pru- 
ritus of the vulva, which is due to vulvar eruptions. Or it may 
be caused by caruncles of the meatus urinarius, vulvar follicu- 
litis, vesical, urethral or rectal tenesmus, haemorrhoids, fissures of 
the anus, or of the vulva, vaginitis, uterine displacements, an irri- 
table uterus, nodular neuromata of the vagina or vulva, or by the 
contact of acrid discharges in utero-vaginal leucorrhcea. 

The most cultivated and gifted women, those of a high moral 
or emotional nature, are most subject to this affection. This is 
especially true of such of them as inherit the hysterical disposi- 
tion, and who are liable to the different forms of spinal irritation. 
All this large class of women are exceedingly prone to be mis- 
mated, and to suffer from personal antagonisms which jar their sensi- 
bilities and derange the sexual sphere. Thus it may happen that 
a delicate, sensitive, impressible woman, who, if she were properly 
mated, would be exceedingly happy and contented, is tied to one 
whose brutal approaches become more and more loathsome and 
repulsive, until finally this morbid sensibility which ruins her 
health and happiness is developed. I have seen one case of the 
kind which really was more painful to witness than anything 
beside that has ever occurred in my professional experience. 
There are no toxical influences which are so difficult to antidote 
as those which arise from sexual incompatibility. 

You need have no difficulty in establishing the diagnosis. First 

54 



850 THE DISEASES OF WOMEN, 

examine the patient by means of the " touch." If she is extremely 
nervous and apprehensive, shakes like one in a 

jOiagnosis. . 

tit ot ague, and is almost or quite convulsed 
the moment the vulva is touched ; if there is a manifest spasm of 
the sphincter and the constrictor muscles of the vagina, so that 
the finger cannot pass into the canal without causing her more or 
less agony, you had better desist, and proceed to put her under 
the influence of an anaesthetic. A few whiffs of ether, or of 
chloroform, will quiet her apprehension, overcome her opposition, 
allay the super-sensitiveness of the vulvar mucous membrane, and 
more than all relax the spasm so that the finger, or speculum, 
will enter quite readily. 

Dr. Sims has given us the differential points in vaginismus in 
one of his laconic sentences: " The supersensitiveness is diagnos- 
tic ; the spasm pathognomonic."* 

The prognosis is generally conceded to be favorable. If, how- 
ever, the disease is the result of a profound lesion of the nervous 
centers, as sometimes, although very rarely, happens, it is not 
likely to be radically cured. Something depends also upon the dura- 
tion of the disease and the serious inroads it has made upon the 
general health. But, in almost every case of vaginismus, you 
will expect to cure your patient, providing your instructions are 
carried out, and she has the patience to wait for the result. 

Treatment. — The treatment is both medical and surgical. The 

remedies most frequently indicated are those which are suited to 

the relief and cure of the intercurrent disorders, 

Medical treatment. . n . . . 

more especially ot menstruation, innervation, 
and digestion, and to the pain and suffering in the bladder, the 
urethra and the rectum. These should be carefully chosen and 
affiliated. I am not aware that any of them hold an especial 
curative relation to the vaginismus separately considered ; nor is 
there on record a well authenticated cure of this disease by .the 
use of internal remedies alone. Belladonna, atropine, thuja^ 
macrotin, sepia, cocculus, conium, platina, mix vomica, pulsatilla, 
hyoscyamus, ignatia, and mercurius, include those which are more 
likely to be indicated than any others. If necessary, (and it often 
is,) either of them can be given in conjunction with the surgical 
treatment. 

*Clinical Notes on Uterine Surgery, by J. Marion Sims, M.D., etc., etc. New- 
York, 1866, p, 320. 



VAGINISMUS. 851 

As usnal in gynaecological questions, authorities are divided on 
the question of employing the knife for the radical cure of vagi- 
nismus. My own opinion, based upon the suc- 
cessful treatment of numerous cases, is that, 
unless there is some especial reason why the cure should be speedy, 
it is best to try the milder means first. This is especially true of 
cases which are not very severe. 

One of the means designed to overcome this disposition to spasm 

of the vaginal muscular fibre is the dilatation of the canal, or 

rather of its constricted portion, by graduated 

Dilatation. . at i 

bougies. An ordinary rectal bougie may be cut 
in two, and one half anointed with simple cerate, glycerine, olive 
oil, or with an ointment consisting of the extract of belladonna, 
one part, and lard or simple cerate, six parts. This may be very 
carefully introduced and allowed to remain, according to circum- 
stances, for a period varying from a few minutes to an hour or 
more, when it should be withdrawn. Of course the patient should 
keep the horizontal posture meanwhile. You may be obliged to 
commence with a very small instrument of this kind, but gradu- 
ally the larger ones can be used, and their presence will be toler- 
ated so that they will no longer occasion pain. The patient can 
soon be taught to introduce and to remove them herself. After a 
time, with proper diet, remedies and regulation of the habits in 
every respect, you will find that it is possible to pass the largest 
size of the rectal bougie without suffering, and that the case is 
practically cured. The complete interdiction of coitus while 
this dilatation is being effected, is a condition of the cure. 

Case. — March, 1862, Mrs. consulted with me for the 

relief of an irritable and sensitive condition of the vagina which, 
during her three years of married life, had caused her untold suf- 
fering, and interfered most positively with sexual congress. She 
was a most intelligent person, frank and candid in her manner, 
and extremely anxious that something should be done for her 
relief, more especially lest her husband should become disaffected, 
and her family and friends continue to ridicule her for never hav- 
ing become a mother. 

On physical examination there was nothing abnormal about the 
external generative organs, except the hyperesthesia of the vulva 
and of the vaginal outlet. The slightest and most delicate touch 
with the finger caused the vaginal spasm immediately, and she 



852 THE DISEASES OF WOMEN. 

was thrown into the same state of suffering which she said she had 
always experienced in the conj iigal act. I placed her under the influ- 
ence of sulphuric ether by inhalation, and these symptoms disap- 
peared. The dilatation with bougies anointed" with the bella- 
donna and simple cerate, was begun and continued every two days 
for a fortnight, then every day for another week, and the barrier 
to intercourse was removed. She soon conceived, and now has a 
son, a beautiful boy, nine years old. I gave her no medicine. 

In most cases to which this plan of dilatation is equally well 
adapted, the cure will not be so speedily effected. It generally 
requires about two months, sometimes a little more, and some- 
times less, to accomplish the desired result. If you prefer, you 
can make use of a series of conical glass dilators, such as I hold 
in my hand, instead of the bougies. These were invented by Dr. 
Sims, and answer a very good purpose. The warm bath and 
electricity are useful auxiliaries to this treatment, in which I have 
gr«eat confidence. Scanzoni treated one hundred cases of vaginis- 
mus by a very similar plan and cured them all without recourse 
to the knife. 

A very few cases are reported to have been cured by excision 

of the irritable tumor which is sometimes found at the mouth of 

the urethra. Others have been remedied by 

Excision of irritable tumors. . 

the removal of the vaginal neuromata, the cure 
of vaginitis, fissures of the parts, and such diseases as could be 
more easily reached and removed by local and general treatment.. 
Dr. Tilt recommends to effect the forcible dilatation of the con- 
strictor muscles of the vagina in the same manner as your pro- 
fessor of surgery, only a few days since, over- 

Dr. Tilt's operation. pi • • ■ 

came a spasm of the sphincter am m a patient 
which he had before you. Having anaesthetized the woman, he 
introduces both of his thumbs with their backs toward each other, 
into the vaginal orifice, and then stretches it firmly and forcibly 
for the space of five or six minutes. After this a plug, or dilator, 
is introduced and kept in position for several days by a T bandage. 
This mode of treatment, however, is not applicable, while there is 
any coincident or remaining uterine or vaginal disease. 

Dr. Sims practices deep incisions on the right and left side of 
the mesial line of the vagina posteriorly. The patient should be 
placed upon the back, and brought thoroughly under the influence 



VAGINISMUS. 



85a 



of ether or chloroform. With a pair of curved scissors remove 
the remains of the hymen. In order to sepa- 

Dr. Sims' operation. ^ ^ ^^ laterally> to opeu the cana l as 

wide as possible, and to draw the tburchette very tense, the index 
and middle fingers of the left hand are to be passed into the vag- 
ina. Then with a common scalpel you make an incision through 
the vaginal tissue, a little to the right side, bringing it from above 
downwards, to the raphe of the perineum, thus making one side 
of a Y ; then insert the knife on the left side and cut obliquely 
toward the other incision, so as to join it at the raphe. Follow 
along through the raphe itself until the cut is Y-shaped. Thus 
the incision will pass across the sphincter vagina for about half 
an inch, but not through it, and, in all will be nearly two 
inches in length, varying in different subjects according to the 
development of tissue in each. 

If t ere is considerable hemorrhage, pressure, the local appli- 
cation of ice or of the per-sulphate of iron will arrest it. If the 
flow of blood is free, but not excessive, the dilator may be intro., 
<luced immediately, and the pressure which it exerts will serve to 




Fig. 128. Sims' Vaginal Dilator. 

nrrest it. Usually the dilator is not applied until twenty-four 
hours after the operation, when it is kept in situ by an appropri- 
ate bandage, after which it is worn " for two hours in the morn- 
ing and two or three hours in the evening, according to the tol- 
erance of the patient." Dr. Sims says: "I have been often 
astonished at the rapidity with which the cuts heal, the process 
being seemingly facilitated by the pressure of the glass dilator, 
which is to be worn daily for two or three hours, or until the 
parts being entirely cured, and all sensitiveness removed, the 
patient may be pronounced competent to fulfill comfortably and 
pleasantly the duty of a wife."* 

♦Bulletin of the N. Y. Academy of Medicine, Vol. I, p. 434. 



854 THE DISEASES OF WOMEN. 

In brief, therefore, Sims' operation is preferred to that of 
Burns', which consisted in dividing the pudic nerve. Some very 
interesting cases cured by Sims' method have been reported by 
Drs. H. B. Clarke, T. Gr. Comstock, W. Tod Helmuth and others. 
You will find a suggestive report on this subject by one of our 
former pupils, Dr. W. A. Burr, of Nebraska, in the current issue 
of the United States Medical and Surgical Journal.^ 

In some of my cases, where the remains of the hymen have con- 
stituted the focal point of the hyperesthesia, I have removed them 

. ,. _. ... with curved scissors and then finished the cure 

Another expedient. _ < 

by means of dilatation and without any incision. 

This treatment will be followed in the case which you saw a few 

moments ago. 

Attacks of vaginismus that are incidental and transient in their 

duration may be relieved by a more simple but equally useful ex- 
pedient. A mixture consisting of chloroform, 

Local anaesthesia. n . -it -t t i • i 

one drachm, and olive on and glycerine, each one 
ounce, may be applied by means of a cotton tampon, providing the 
spasm of the vagina does not prevent its introduction into that 
canal. In that case it may be thrown into the rectum, when the 
spasm will very soon cease. Afterwards the proper medical and 
hygienic treatment can be resorted to for the radical cure of the 
conditions, or diseases, upon which these paroxysms are contingent. 

tVolume VII, page 367. 



LECTURE LII. 

LACERATION OF THE CERA^IX UTERI. 

Laceration of the uterine cervix. Discovery and description of. Clinical history. 
Causes. Symptoms, subjective and objective. Varieties. Cervical ectropium. Fol- 
licular degeneration. Cicatrization. Diagnosis. Complications. Laceration with 
sub-involution, epithelioma, peri-metritis, and sterility. Prognosis. Treatment, 
preventive, preparatory and operative. Trachelorrhaphy. The after-treatment. 

Your clinical advantages would fail of improvement if we did 
nGt mid time to consider the subject of laceration of the cervix 
uteri. And my course upon gynaecology would be very imperfect 
without a practical talk upon this very important lesion. The 
Discovery and de- discovery of the frequency of these lacerations, 
scription of. f their significance as a source of chronic uter- 

ine disease, and the development of a proper and successful plan 
of treatment for them, is of recent origin. In 1868 Dr. M. A. 
Pallen, of St. Louis, and in 1869 Dr. Thomas Addis Emmet, of 
New York, were the first to publish their experience, and to 
draw the attention of the profession to this very important 
subject. 

Clinical history. — You are aware that certain lacerations of the 

soft parts, as for example, of the fourchette, and of the vaginal 

mucous membrane, are incident to labor, for you have studied 

their relation to puerperal sepsis and pvaemia 

Puerperal lacerations. . . , 

in our puerperal wards, fissures in the mucous 
membrane, and fistuloe of the septa between the vagina and the 
rectum, and between the vagina and the bladder, as well as rup- 
ture of the perineum, are sequelae of childbirth that are pretty 
thoroughly understood and managed by the skilful gynaecologist. 
But the lesions of the cervix which take the form of lacerations 
are, it seems, quite as frequent and as serious in their conse- 
quences. 

Two things are illustrated by the discovery that these wounds 
of the cervix underlie and complicate many of the diseases of 
women: (1) the tendency to exclusive, one-sided, routine ideas 
in uterine pathology, an<? <2) the possibilitv of overlooking 

855 



850 THE DISEASES OF WOMEN. 

what would certainly be seen, if we were more careful and less 
prejudiced. 

If the profession had not accepted the dogmas of Dr. Bennet 
concerning induration and ulceration of the cervix as the essen- 
Mischievous effects tial factor in the diseases of women, and prac- 
of dogmatism. tised accordingly, it would have been impossi- 

ble that the speculum could have been used for twenty-five years 
without recognizing the frequency and importance of these lac- 
erations. If the displacement theory had not substituted the 
question of uterine statics for the exercise of a little good sense 
and discrimination, these lesions of the cervix would have been 
sought for long ago, and no one would have made himself ridicu- 
lous by proposing to cure them by means of an abdominal sup- 
porter, or a harness ol any description. 

The world moves, and this time at least, the women get the 
benefit of it. If his followers do not run to the other extreme 
and mutilate the cervix to make out a case, or multiply these lac- 
erations without limit, Dr. Emmet's innovation will prove a bless- 
ing to all concerned. 

Causes. The clinical history of cervical lacerations almost 

always dates from labor, either an abortion, or at term. When 
you find a rent which has changed the form and the extent of the 
os uteri you may be confident that something has been extruded 
through the cervical canal. The delivery of a polypus, a fibroid, 
a cluster of so-called hydatids, the decidua-menstrualis, or even 
of clots during menstruation may produce this effect. But, as 
with a rupture of the fourchette, this form of laceration is most 
frequent in case of primiparae. 

It is a contingent of a premature discharge of the liquor amnii, 
and of delivery, before the cervix is properly expanded ; of too 
rapid labors; of tedious labors from malpresentations ; of the 
traumatism of an impracticable delivery; of the resort to version, 
whether podalic or cephalic ; and of instrumental delivery with 
the forceps, the blunt hook, or by craniotomy. It is sometimes 
due to the forcible dilatation of the cervix during labor in cases 
in wdrich there is a cancerous infiltration of the tissues, or where 
there are cicatrices that have resulted from incisions, and from 
excessive cauterization of the neck of the womb. 

Sympto?ns. If there were any subjective symptoms by which 



LACERATION OF THE CERVIX UTERI. 



857 



Subjective symptoms. 



a laceration of the cervix could be known, its clinical history 
would have been written long ago, and a great deal of mischiev- 
ous treatment might have been averted. But 
while there are no such signs of this lesion, 
there are symptoms which suggest it, and which render it very 
probable. Cervical laceration is so often associated with sub- 
involution of the uterus that the most prominent symptoms of 
chronic metritis are seldom lacking. This, you know, includes 
increased weight of the organ, prolapsus, menorrhagia, uterine 
leucorrhcea, intra-pelvic and sacral pain and distress, and an ina- 
bility to stand or to walk about. In some cases there is a form 
of neuralgia of the neck of the womb, and of the neighboring 
parts which creates an intolerance of coitus, and which may even 
simulate vaginismus. Headache, lassitude, neurasthenia, melan- 
choly, and a kind of hopeless invalidism are almost always present 
in chronic cases. 




Fig. 129. Unilateral laceration separated by a double tenaculum (Emmet). 

The objective symptoms will vary with the kind and extent of 
the laceration itself; the consequent deformity of the cervix; 
the ectropium or the e version of its lining mem- 
brane ; the hyperplasia ; and the cystic degen- 
eration of its follicles; the friction of the parts against contigu- 
ous surfaces, and the partial cicatrization of the wound, as well 
as the effects of repeated labors and abortions. 



Objective symptoms. 



858 



THE DISEASES OF WOMEN. 



There are three varieties, of cervical lacerations ; (1) the uni- 
lateral, (2) the bilateral, and (3) the multiple or stellate. These 
beautiful drawings will give you an excellent 

Varieties k ' 

idea of them. (See Figs. 129, 130, 131.) The 
charts also represent the enlarged Nabothian follicles, which are 
almost always present in these cases. 




Fig. 130. Stellate laceration of the cervix (Emmet). 

The extent of the laceration varies. Sometimes it' is so slight 

a nick, and so superficial as scarcely to be noticed,. 

The degree of the anc j ^ ma y even ^ e limited to the mucous mem- 

laceration. „ , ■, i • i 

orane of the cervical canal without passing 
through the external os. In this case it is called a fissured, or 




Fig. 131. Bifid laceration of the cervix (Emmet). 

partial laceration, and is apt to be accompanied by endo-cervicitis 
with a trivial ectropium. Again the lacerations are deep enough 



LACERATION OF THE CERVIX UTERI. 



859 



to extend through the whole length of the vaginal cervix in 
which case the anterior and posterior lips will be turned out- 
wards. 

In the puerperal uterus the lacerations often occur in the 
antero-posterior direction, through one or both lips, but because 




Fig. 132. The margins of a recently-lacerated cervix. 

the position of the lying-in patient keeps the rent closed, a spon- 
taneous cure is the result, and we seldom meet with these cases 
outside of the lying-in. Before they come into our hands they 
are already cured. 

The eversion of the cervical endometrium, which is extruded 
like a haemorrhoidal tumor, is not always in 

Cervical ectropium. . . , , n . T , 

ratio with the extent of the laceration. 11 the 
rent is very large the hyperplasia of the cervix may be such as to 
prevent the rolling out of its lining membrane; while, even if 
the wound is small and there is little or no hyperplasia, the ever- 
sion may be comparatively large. It is the chafing and erosion of 
this extruded mass which induces the granular, elevated, bleed- 
ing, and profusely secreting surface that is generally supposed to 
be ulcerated. 

The cystic degeneration of the follicles of Naboth was once 
regarded as a fair sign of chronic metritis; and I have often 



860 



THE DISEASES OF WOMEN. 



known it to be mistaken for acne and other forms of eruption 

upon the cervix uteri. When these follicles 

follicular degenera- become hypertrophied and drop through the 

external os, they sometimes develop into vas- 
cular polypi. 

Lacerations of the cervix that are chronic, and not fresh or 
cicatrization recent, are apt to be partially or wholly cica- 

trized, in which case if the lesion is extensive 
the touch may incline you to think of cancerous infiltration or 




Fig. 133. The false cervix composed of reflected vaginal tissue and everted intra-uterine 

tissue. 

deformity, or perhaps of phagadenic ulceration with a scirrhous 
margin. These ununited lacerations are sometimes very decep- 
tive, because if neglected, they may tend to the production of 
epithelioma, or of cervical or corporeal fungosities of a suspicious 
character. 

Repeated, or rapid childbearing is sometimes followed by the 
worst forms of cervical laceration, the lesion 
being increased with each succeeding labor. 
And recurrent abortion, especially if it has been criminally in- 
duced, may have a similar effect. 



LACEKATION OF THE CERVIX UTERI. 861 

Diagnosis. — Unless you drag the womb to the vulva and ex- 
amine the cervix without a speculum, which 

Inspection of the wou l c | ^ e crue l m most case s, VOU will UOt have 
cervix. 7 J 

a correct and satisfactory idea of the cervical 
laceration, without a resort to Sims' speculum. When the peri- 
neum is fully retracted, and the depressor has carried away the 
anterior vaginal wall, the cervix will be more fully exposed than 
if you used a cylindrical or a bladed instrument. My friend, 
Prof. Comstock, prefers Erich's speculum, which is also a retrac- 
tor, and is self-retaining. 

But the mere inspection of the cervix uteri will not tell the 

whole story, else it would have been written 

gatdlo^ 1 " faCUa rG ' lon g a £°- For < stran g e as ^ ma y appear, these 
rents were seen many thousand times before 
their clinical significance was interpreted by Dr. Emmet. If you 
look over my collection of colored drawings showing the varie- 
ties ol ulceration of the os uteri, as they are delineated by our 
best authors, you will find that in almost every case you have a 
picture of some form of laceration of the cervix. Turn to your 
books, and, if you except the corroding and other forms of malig- 
nant ulceration, you will observe that almost every cut which is 
designed to illustrate a case of ulceration of the os really gives 
you a sample of cervical laceration. It seems incredible that 
men who had devoted their lives to a specialty should have been 
so insufferably stupid, and that their preconceived ideas should 
have had such a blinding influence upon their faculty for observa- 
tion. 

• Having exposed the cervix as already directed, the tAVO lips 
may be seized with a double tenaculum (Fig. 

^Examination of the m ^ ^ the ^^ Qf ^ ^^ g() separated ag 

to enable you to form an idea of the length, 
direction, and depth of the laceration. (Fig. 132). Or you may 
seize each lip of the cervix with a separate tenaculum and draw 
the margins of the wound together, when the form and outline 

of the normal' cervix will be apparent. It is 

The certain test. ., i i • 

possible, however, that the ectropium and the 
hyperplasia may prevent the rigid application of this test. If 
you can close the lips of the wound so as to conceal the eroded 
mucous membrane, and to cover up the granular ulceration, the 
diagnosis is plain enough. 



S62 



THE DISEASES OF WOMEN. 



Complications. — From what has already been said you will infer 
that except in the puerperal uterus, a laceration of the cervix is 




Pig. 134. A double uterine tenaculum. 

always complicated with other uterine affections. The most fre- 
quent of these coincident disorders is a form of abrasion, or 
erosion of the mucous membrane which is apt to be regarded as 
granular or follicular ulceration. After this is the hyperplasia, 
or benign hypertrophy of the cervix, which was treated by 
Bennet and his followers as an induration of the cervix. The 
cystic degeneration of the follicles of Naboth, which has often 
been described as an eruptive disorder, with a shot-like feel and a 
tendency to the development of vesicles and of pustules, is sel- 
dom lackino- in confirmed cases of laceration of the cervix. 

Another form of uterine disease that often depends upon a 

laceration of the cervix is subinvolution, with 

its accompanying menorrhagia, prolapsus, or 

other displacement, uterine catarrh, dyspar- 

eunia, and intra-pelvic pain and distress. In a former lecture 

(Lecture XXII.,) I have discussed this subject very thoroughly. 

When speaking of epithelioma of the cervix (Lecture XLIII.,) 

I directed your attention to the theory, that 

Epithelioma and lac- the abrasion and f r i ct i n of the cervical endo- 

eration. 

metrium, when it had been extruded through a 
lacerated os, was a fruitful source of cancer of the neck of the 
womb. It is not at all improbable that the great comparative 
frequency of cancer in the glandular portion of the cervix uteri 
is due to these avoidable conditions, and that when we are better 
able to recognize and to remedy these lacerations, it will be less 
frequently met with. 

Some cases of laceration of the cervix are badly complicated 



Subinvolution and 
laceration. 



LACERATION OF THE CERVIX UTERI. 863 

with pelvic abscess and with pelvic peritonitis. In the former, 
the real obstacle in the way of cure is the scrof- 

peri-metritisandiac- uloilg diathesis ; while In the latter, the men- 
oration. . . . 

strual return is a relapsing factor which is very 

-difficult to overcome. 

Many cases of sterility are traceable to a forced abortion which 

has resulted in laceration of the cervix. As 

Sterility and lacera- j ag lg56 thQ kt and lamente a Dr. A. 

1;.on. ° = 

K. Gardner, of New York, wrote as follows:* 

" Among the married, lacerations of the os and cervix in a first 
'-confinement are not imfrequently followed by subsequent barren- 
ness. The accompanying symptoms being those of dysmenorrhcea, 
and the severest forms of uterine disease, profuse leucorrhcea, etc. 
Examination shows immense hypertrophy (in some cases the en- 
larged os becoming too voluminous to be entirely displayed at 
one view by a four-blacled speculum); the fissures often two or 
three in number, extending an inch or two through the neck 
towards the body of the uterus, their edges uncicatrized, the 
whole observable organ highly injected, and the entire apparatus 
bathed in a profuse and often fetid muco-purulent discharge." 

Pi^ognosis. — With proper precautions in the way of prepara- 
tion, of freshening the surfaces, of careful adjustment, and of the 
after-treatment, the great majority of cases are curable by a sin- 
gle operation. h\ a few the operations will need to be repeated 
once or twice; and in fewer still it will fail altogether. Fresh 
cases, if they are not too near the lying-in, will recover more 
readily than older ones. The larger the amount of cicatricial 
tissue, or the more fungoid and irritable the granulations, the 
more difficult and unpromising the case. If the everted mucous 
membrane has taken on what is known as the cock's-comb ulcera- 
tion, or if there is something of the cauliflower excrescence, the 
prognosis should be carefully qualified. Indeed, in the latter 
-case it would be a question whether the operation would be expe- 
dient or advisable. 

Treatment. — As you will soon be engaged in the general prac- 
tice of your profession, it will be in your power to do a great deal 
for the prevention of this troublesome infirmity. 

Prophylaxis of L r 

In this connection Dr. Comstock s remarks are 
very appropriate : 

* The Causes and Curative Treatment of Sterility, etc., by Augustus K. Gardner, A. M., 
M. D.. p. 96. 



864 THE DISEASES OF WOMEN. 

" The practice of obstetrics has been greatly simplified during- 
the past twenty years, and corresponding with the improvements^ 
in the art, after-lesions are much less frequent now than formerly. 
The enlightened practitioners of this day have learned two or 
three lessons in obstetrics. (1). In natural labors not to interfere 
or rupture the membranes at too early a stage. (2). In breech 
presentations, to preserve the bag of waters as long as possible, 
and by no means to interfere until after the expulsion of the 
breech. (3). In protracted labors to shorten them by the timely 
application of the forceps. (4). In the third stage of labor, not 
to be in a hurry to extract the placenta, but during the delivery 
of the child to apply the hand over the womb and to keep it 
there, exercising a gentle but rather firm pressure, assisting the 
womb to contract, in other words, resorting to a vis a tergo, and 
only in very exceptional cases making traction upon the cord, 
vis a f route, so that the placenta is expelled by nature and we 
thereby have a complete contraction ot the womb, and conse- 
quently normal involution follows." 

The preventive treatment ot cervical lacerations includes the 
proper care of the puerperal as well as of the parturient woman. 
For, if you are careful to keep the lying-in patient in bed for a 
sufficient length of time, to surround her with suitable hygienic 
conditions, to supply her with good food and fresh air, and to 
wash the vagina and the vaginal cervix with calendula water and 
glycerine, the fissures and lacerations may often be cured before 
the woman comes into the hands of the gynaecologist. As I have 
already said, lacerations through the fore-lip or the hind-lip, in an 
antero-posterior direction are more likely to heal spontaneously 
in child-bed than are those which are lateral. 

The preparatory treatment is very important. If there is a 
considerable degree of circum-uterine inflammation in the form 

Th- pre aratory °^ cellulitis or of peritonitis, the operation 
treatment. should be deferred until the more serious effects 

of those lesions are disposed of. You have seen several cases of 
this kind in my sub-clinic. Under these circumstances, as well 
as for the relief of the engorgement of the cervix, and of the 
hyperplasia, you may try the effect of vaginal irrigation of hot 
water. An injection of a gallon or more may be thrown into the 
vagina once or twice daily for a week or more, and while the pa- 
tient is taking internal remedies. The tumefaction and tender- 
ness, as well as the congestion and the deformity of the cervix 
may sometimes be gotten rid of by puncturing the hypertrophied 



LACERATION OF THE CERVIX UTERI. 8Q5 

follicles and allowing their contents to escape. Extensive abra- 
sions of the everted mucous membrane may be soothed and 
healed temporarily by the application of a mixture of cosmoline 
or vaseline and the muriate of hydrastin, or by the local use of 
glycerine and calendula,. 

Bearing in mind that there is in certain women a kind of toler- 
ance of lesions of the soft parts arising from the 
^fo/opSS 018 traumatism of labor, and which in those who are 
differently constituted, will induce ill health and 
chronic invalidism; you must select your cases for operation 
accordingly. It is not every case in which an extensive rent in 
the uterine cervix will offer the strongest plea for surgical relief. 
The number of labors at term, or prematurely, that the patient 
may have had, more especially if they have taken place either 
very rapidly or at long intervals, will make the operation more 
imperative. A mere rent in the cervix is not necessarily a cause 
of disease, and while first labors often give rise to serious mischief, 
it may happen that a young mother shall escape the penalty alto- 
gether until she has been through other and subsequent deliveries. 

You would not perform Emmet's operation in one who is the 
subject of chronic pelvic cellulitis, or peritonitis, 
Caution. acute metritis, salpingitis or ovaritis ; in one who 

has had a menstrual hematocele, chronic retro- 
version, an abdominal tumor, cauliflower excrescence, or any form 
of malignant disease, neither during pregnaucy nor puerperality. 
Rembering what Verneuil has said of the failure of plastic opera- 
tions in diabetic subjects, if there is any sign of a morbid cachexia 
the urine should be tested for sugar before the operation is made. 
The indications for hystero-trachelorrhaphy should not be exag- 
gerated, or unduly magnified, as has too often been done. 

The proper time for operating is within the week following the 
monthly period. If the interval is normal this 
The o b pemtini efor will afford sufficient time for the wound to heal 
before the flow returns. In case the menses are 
too frequent it is better to operate directly after the period. When 
the operation is made upon one who has not menstruated for sev- 
eral months as, for example, during lactation, a very common result 
of the operation is to restore the flow, and sometimes even to in- 
duce a menorrhagia. 



866 THE DISEASES OF WOMEN. 

Women naturally suppose that so serious a thing as a surgical 
operation will put a sure and speedy end to their 
a precaution. suffering, and unless you explain beforehand 
that the good which is to follow in their case is 
likely to be gradual, they will be disappointed and you will be 
blamed. For it is not reasonable to promise that a train of morbid 
symptoms which have been developing for months, or for years, 
will be entirely disposed of so soon as the wound has healed. The 
fact is that the improvement will be slow and almost impercepti- 
ble at first, and even months may pass before the patient will fully 
realize the benefits of the operation. 

EMMET'S OPERATION, OR HYSTERO-TRACHELORRHAPHY. 

The patient should be placed upon a short, firm table, rather 
than upon an operating chair. The table should be dressed with 
a pad covered with rubber cloth. The anaesthetic should be 




Eig. 135a. One-half of Corastock's gynaepods in position. 

administered by a responsible physician, whose business it is to 
attend to that and to nothing else. You will need a plentiful sup- 
ply of hot water; a few small and very clean sponges; a Sims' spec- 
ulum and retractor; tenacube; scissors that are curved on the flat 
and sharp-pointed, a scalpel, two or more sponge holders, and the 
proper needles and sutures. 

When the patient is fully anesthetized, her hips should be 
brought to the edge of the table, which has been placed in a good 
light, and the proper position chosen for the operation. Either 
she may lie upon the back or upon the left side. In the dorsal 



LACERATION OF THE CERVIX UTERI. 867 

position the limbs may be held by assistants, or they may be 
placed in Comstock's gymepods (Fig. 135) or in Walton's foot-rest. 
In lieu of a sufficient number of assistants the latter will need to 
be supplemented by Peters' leg-brace in order to steady the limbs. 
The first thing to be done is to cleanse the vagina, antiseptically, 
providing it has not been done before coming to the table. The 
next step is to secure the cervix and to bring it as freely into view 
as possible without the use of too much force. By passing a Sims' 
speculum the os is exposed, and one margin thereof is to be seized 
with a volsellum, or with a double tenaculum and gently drawn 
toward the vulva. 

A stout needle, armed with a long piece of strong carbolized silk 
is now passed from above downwards through both lips of the 
cervix and through the portion which corresponds with the cervi- 
cal canal. This thread may be caught with a tenaculum and 
divided so that there shall be one for each lip of the cervix. When 
these are tied separately they constitute the loops by which these 
portions of the organ are to be held. The volsellum may now be 
removed. If you prefer to use the double tenaculum the loops 
will not be necessary; or, if the patient is in Sims' position the 
nterus can be held down by a single tenaculum which is securely 
placed at the angle of the wound. 

The process of freshening, or the vivification of the edges of the 
wound, is a very important part of the operation. The ordinary 
surgeon is very apt to cut away more tissue than is necessary, 
while the novice in this work will take too little. 

There has been some confusion of terms as to the cicatricial 
tissue which is foreign to the cervix and which needs to be remov- 
ed. There is no actual plug there, but there is a varying amount 
of indurated tissue, more especially in multipara^ and in those 
who have been repeatedly cauterized, and about the angle of tlie 
wound, which you must cut away. Sometimes this hetero-plastic 
formation dips down along the sides of the wound and extends 
farther than you would suppose, but, like the bits of a necrosed 
bone, it must all come out. In bifid and stellate lacerations we 
excise the redundant tissue and convert them into unilateral or 
bilateral wounds. Not only must we trim the edges of the rent, 
but the enlarged Nabothean follicles must also be carefully cut out. 
The best sign that all foreign tissue has been removed is furnished 
by the touch, which recognizes the normal uterine structure. 



868 



THE DISEASES OF WOMEN. 



The freshening may be done with the scissors or with the scal- 
pel. The most thorough separation of the morbid tissue at the 
angle of the wound is secured by the use of Skene's parrot-bill 
scissors (Fig. 136a) but, if the laceration is a \erj deep one there 
will be a risk of wounding a branch of the circular artery. The 
hemorrhage which varies in different cases, is easily controlled 
by the use of hot water applied by sponges or by irrigation with 
the syphon, or by hemastatic forceps. If the laceration is a double 
one, having freshened one side, you may save time by applying a 
hot sponge to the denuded surface and leaving it there while the. 
other side is being prepared. 




Fig. 135b. The closed laceration (Thomas.) 

When the wound has been thoroughly cleaned of blood and of 
clots it is ready for the sutures. For passing them a straight glove 
needle, w T ith a sunken eye that will not be crushed in the forceps, 
is the best. Curved needles are awkward and uncertain; for you 
never know how deep they are going or where they will emerge. 
The Russian needle holder (Fig. 136b) will carry the straight 



LACERATION OF THE CERVIX UTERI. 869 

needle where you want it, and since so much depends upon the 
coaptation of the lips of the wound, this part of the work should 
be carefully done. You have seen me do this so often in my clinic 
that I need not particularize, except to say that the first suture 
should be passed at the angle of the rent, and that if it is properly 
adjusted there will be no danger from hemorrhage. The sutures 
must not be too tightly drawn. The number and nearness of the 
remaining sutures will vary with the case, the rule being that 
more of them are required if the cervix is very large, or the tear 
is an old one, or if there has been much venous flow, or if a great 
deal of cicatrical tissue has been removed; or if there is a proba- 
bility of the almost immediate return of the menses. You should 
always count the sutures that are passed, and keep a record of 
them in order that none of them may be left behind when the 
time has come for their removal. 



Pig. 136a. Skene's parrot-bill scissors. 

The sutures may consist of carbolized silk, cat-gut, horse-hair, 
silk- worm gut, or of silver wire. As to which you shall take, the 
silver wire is undoubtedly the best, but, excepting the cat-gut, the 
others may answer. Before putting in the last stitch on either 
side of the os-uteri I always take the precaution to pass the uterine 
sound and to leave it there while the needle is introduced, lest the 
canal of the cervix should be closed, an accident which has hap- 
pened to others. The sutures should be bent at right angles with 
the wound and cut off squarely so that they will not injure or worry 
the soft tissues. The use of the perforated shot and the rubber 
tubing for keeping them in position is now very properly dis- 
pensed with. (Fig. 135b). 

When the inverted structures have been turned within the canal 
of the cervix, and the edges of the wound brought together, they 
should fit like the seam in the finger of a glove. The wound should 
be sponged off carefully and the instruments removed. If the 
womb is likely to recede very far, or the cervix to be inaccessible, 



870 THE DISEASES OF WOMEN. 

there is no objection to leaving one of the loops in situ so that it 

may be drawn down when the sutures are to be removed. Before 

the patient is placed in bed the womb should be gently and firmly 

lifted into its normal position. The after-treat- 

The after-treatment, ment is almost entirely negative, especially for 

the first thirty-six hours. Until the effect of 

the anaesthetic has passed she should lie upon her back, after that 

it will be safe for her to lie upon either side or to be changed from 

one side to the other. 

For the first twelve hours the urine had better be drawn, but 
after that she should be allowed to pass it into the bed-pan. I am 
satisfied that the prolonged use of the catheter is productive of 
mischief, particularly when the bladder is sensitive and when it 
has been more or less traumatized by the forced descent of the 




Fig. 136b. The Russian Needle-holder. 

uterus. We must refrain from making any local application what- 
ever to the wound within the time specified. This will give it 
time to heal by the first intention, and the plasma thrown out 
will not be washed away by any undue interference. After that a 
mixture of calendula and glycerine in equal parts, a tablespoonful 
of each to a pint of warm water, may be injected very gently by 
the fountain syringe morning and evening. If, after some days, 
the discharge is offensive, a few drops of carbolic acid or listerine 
may be added to the mixture. If there is no fever, and there usu- 
ally is none, she may be allowed a good nourishing diet. The 
bowels should be kept open and soluble, and if the menses return 
within the first fortnight, remedies should be given to keep the 
case from developing into one of menorrhagia. 

Nothing will be gained but much may be lost by the too early 
removal of the sutures. My own experience has taught me to leave 
them in situ for ten or twelve days, and, should the menses recur^ 
to pospone still longer, indeed for some days after the flow has 
ceased. 

I have several times thought to take them away, but on exami- 
nation have found only an imperfect union of the parts, and by 
waiting a little have afterwards obtained a good result. As a rule 



LACERATION OF THE CERVIX UTERI. 871 

tlieir removal can be most easily effected with the patient lying on 
the side. Of course the sutures should be cut and not untwisted, 
else the good result will be spoiled. The principal objection to 
the silk suture is that it may need to be removed before the wound 
has firmly closed, and the cat-gut would not hold long enough to 
be of any real service. 

The only cases in which I employ the cat-gut sutures in Emmet's 
operation is to secure greater accuracy of adjustment, and where 
it is expedient (it is not always so) to repair the uterine cervix and 
a torn perineum at one sitting. Under these circumstances, if the 
rent in the cervix is shallow, with but little cicatricial tissue, and 
there is no strain upon the lips of the wound, I sometimes stitch it 
up with large-sized cat-gut, and put one suture of silver wire on 
each side of the os-uteri. This is sufficient, and the wire sutures, 
after remaining for two or three weeks, can be easily removed with- 
out injuring the perineum. 

If the case was not unusually severe, my practice is to allow the 
patient to sit up a few hours at a time, beginning at the end of a 
week. When the sutures have been taken she may move about 
the room a little, but should be cautious not to overdo. With the 
return of the first period she should go into a menstrual quaran- 
tine. 

In a considerable share of cases Emmet's operation has resulted 
in the cure of sterility. In subsequent labors there is no increased 
risk of re-laceration. 



LECTURE LIII. 



VESICO- VAGINAL FISTULA. 

The varieties of vesical and vaginal fistulae. Vesico-vaginal flstulce. Causes, from child- 
birth, from wounds, from calculi, from syphilis, cancer, etc. Symptoms. Case. — 
Physical signs of. Case.— Prognosis Treatment, in recent and in chronic cases, by 
cauterization, and by Sims' operation. Case.— Recto-vaginal fistula}. Causes. Physi- 
cal signs. Prognosis. Treatment by surgical procedure. 

There are several varieties of fistuloe which open into the blad- 
der and the vagina. The names that are applied to them indicate 
the cavities which are thus made to communi- 
varieties of vesical t Unnaturall y. For example: A vesica- 

and vaginal flstulae. J > ' 

vaginal fistula is one in which there is an open- 
ing between the bladder and the vagina; a vesico-uterine fistula 
implies that the uterus and the bladder communicate; in a recto- 




Fig. 137. Diagram showing the principal varieties of vaginal fistulas. 1. The fundus 
uteri. 2. The rectum. 3. A utero-vesical fistula. 4. A vesico-vaginal do. 5. A recto- 
vaginal do. 6. The vagina. 7. A urethrovaginal fistula. 8. The urethra. 

vaginal fistula the wall that separates the vagina from the rectum 
is perforated ; in a urethro-vaginal fistula the urine may escape 
into the vagina without passing through the meatus-urinarius. 

8~2 



VESICOVAGINAL FISTULA. 



873 



The site of these several lesions is shown in this drawing. (Fig*. 
137.) 

There are other kinds of genital fistulae in women that are 
more rarely seen. Thus we may have a vesico-utero-vaginal, a 
ureto-uterine or a ureto-vaginal fistula, a redo labial, an entero- 
vaginal, a perineo-vaginal, or a peritoneo- vaginal fistula. But, of 
the urinary fistulee, the vesico-vaginal is by far the most frequent; 
while of the fecal fistulae, the same is true of the recto-vaginal 
variety. 

I shall first speak of those cases in which there is a fistulous 
orifice between the bladder and the vagina. In these fistulas the 
opening may be so small that Ave can find it only by injecting the 
bladder with colored water and then watching for its means of 
escape, or large enough to involve the whole posterior wall of 
that viscus. In the case of large-sized fistulae the older they are 
the smaller they become. 

Here is an excellent model which I brought from Paris that 
shows the exact relation of the parts in vesico-vaginal fistula; 




Fig. 138, A vesico-vaginal fistula. 1. The fundus uteri. 2. The rectum, 3. The retro- 
uterine pouch. 4. The bladder. 5. 1 he vagina. 6. The fistulous opening. 

and this diagram (Fig. 138) will give you a correct idea of the 
lesion when it is located above the bas-fond of the bladder. 

Causes. — The chief cause of vesico-vaginal fistula is the pres- 
sure of the foetal head against the pubis in labor, and the trau- 
matic inflammation and sloughing that follow it. It is, therefore, 



874 THE DISEASES OF WOMEN. 

a contingent of difficult and tedious delivery. In rare cases it is 
undoubtedly caused by the hasty and improp- 
birth 0n8m m Chld " er use °f tne ODS tetric forceps, more especially 
by the up and down, or pump-handle move- 
ment of the instrument while making traction. More rarely still 
these fistulas have been caused by the wearing of an ill-adjusted 
pessary, or of one that has been left in the vagina after it has 
decomposed and o-iven rise to ulceration and 

Other causes. \ ^ . 

sloughing oi the vesico-vagmal septum. I hey 
may also arise from injury during craniotomy. In other cases the 
bladder has been perforated by needles or pins that have been 
passed into it through the urethra, and by vesical calculi compli- 
cating labor, as well as by syphilitic and cancerous ulceration. 
This variety of fistula is a possible result of puerperal vaginitis; 
and I have already told you (Lecture XXXVI.) that it is some- 
times induced artificially in the treatment ot cystitis, and of stone 
in the bladder. 

Symptoms. — The first symptom to attract attention is a more or 

less constant and involuntary flow of urine, 
The pathognomonic ^^ commences at a period varying from three 

sign ot. l j n 

to thirty days after delivery. This dribbling is 
usually noticed within the first week, but where there is a large 
slough, more especially from puerperal vaginitis, it may not 
come on until a fortnight or more has elapsed. The fact that the 
lesion is always upon the posterior wall ot the bladder, or about 
its sphincter, usually renders the flow of urine constant while the 
patient is lying down ; but exceptionally it may be relieved by 
this position. If the fistulous orifice is above the insertion of the 
ureters, she may be able to retain a considerable quantity of urine 
while standing. One of my patients had arranged a sort of time- 
table to the capacity of the bladder, and for six years had seldom 
allowed the urine to overflow into the vagina. In her case the 
fistula v^as small and very high. It was cured by a single opera- 
tion. Courty reports the following: 

Case. — I have lately seen a young woman with a fistula which 
would readily admit the first phalanx of the index finger, but in 
spite of its size, by a singular mechanism, the urine was habitually 
retained in her bladder, sometimes for an hour, and escaped only 
when she was obliged to let it go suddenly. This result was clue 
to the fact that by the settling down of the uterus the vesical 



V.KSICO- VAGINAL FISTUL^E. 875 

mucous membrane in the median line was made to cork up the 
orifice, after which the urine accumulated in the right and left 
diverticula of of the bladder.* 

In acute cases the overflow, or incontinence of urine is almost 

always preceded by haemorrhage, and, if the slough is extensive, by 

the discharge of bits and shreds of tissue. The parts have been 

rendered so insensible by the traumatism of labor 

In recent cases. J 

that there is little or no pain. But, when the 
case has become chronic, the symptoms are apt to include those of 
an inflammation of the neighboring parts, as vaginitis, with 
spasmodic constriction of the passage, vulvitis, cystitis, endo- 
metritis, and even pelvic cellulitis and peritonitis. 

In extreme cases the soft parts may have sloughed so generally 
that little or nothing of the vaginal canal is left. The worst ex- 
ample of this kind that I have ever seen was sent to me two years 
ago from New Orleans by my friend Dr. W. H. Holcombe. The 
lesion had resulted from a labor which had lasted actively for a 
week, and which was finally ended by the use of the forceps. The 
patient lived in the interior of the southern country, and could 
not have the proper medical assistance. 

I shall never forgive you if in your note-books, you place the 
credit of this terrible result either to my friend Holcombe, or to 
the forceps, for, unfortunately for the poor victim, neither the one 
nor the other of these excellent agents was within her reach at the 
right time. 

Beside the symptoms already given, the unnatural flow of the 
urine over the vaginal mucous membrane causes irritation, exco- 
riation and ulceration, with vesicular eruptions erythema and pru- 
ritus of the vulva, the perineum, .and even of the thighs. In old 
cases the edges of the wound are often covered with incrustations of 
phosphatic deposits that break and fall into the vagina, and that 
cause great pain and discomfort. Sometimes these deposits accum- 
ulate within the bladder, whence they will need to be removed 
through the fistulous opening or the dilated urethra before an 
operation for the radical cure is made. 

The physical signs are obvious and satisfactory. In minute 
capillary fistulas you may need to resort to the expedient already 

* Traite pratique des maladies de 1' Uterus, des Ovaries et des Trompes, par A„ Courty- 
Professor, etc., Paris-. .1872, p. 1,199. 



bib THE DISEASES OF WOMEN. 

given. But in all ordinary cases, the touch conjoined with the 
The physical signs. P assa g e of the catheter through the urethra, or 
what remains of it, and out through the wound 
into the vagina will detect the rent. And the use of a Sims' spec- 
lum in the semi-prone or the prone position will reveal its site 
and dimensions, and make it thoroughly accessible. 

In March, 1874, Dr. T. M. Martin, a member of the class from 
Wisconsin, brought a woman to my clinic who had had a vesico- 
vaginal fistula for sixteen and a half years. The following is the 
record of her case : 

Case. — Mrs. , aged 34, was married eighteen years ago. 

Her first child was born eighteen months after, the labor being 
very severe and prolonged. Her mother says that the head of the 
child becoming impacted in the pelvis, the attending physician 
gave her considerable quantities of ergot in order to complete the 
delivery. But this failed, and two other doctors, who found it 
necessary to resort to craniotomy, were called in. After this 
operation she was very ill, and came near dying. In five or six 
days the urine began to run away, and from that time until now 
(sixteen and a half years) she has neve.' passed it naturally, nor 
has she been able to retain it for a moment, in any posture, after 
it has been discharged from the ureters into the bladder. 

For two years after the accident she was a cripple* during the 
first of which she could not stand upright, and throughout the 
second year she was obliged to walk on crutches. Her general 
health, however, did not really mend until she again became preg- 
nant. She reached term, and was safely delivered of her second 
child; and now, in all, she has had six children since the fistula 
was formed. These children were born without instrumental aid, 
and are alive to-day. 

Her mother, who has been her nurse, and who used frequently 
to dress the fistula through a speculum, is confident that the 
opening into the bladder has become a little smaller with each 
successive confinement. For the most part, for seven years she 
was compelled to remain either in bed or in a sitting posture. 
The general health is now good, but she is a pitiable martyr to an 
incessant flow of urine. 

I made the operation before the whole class, when it was much 
smaller than now, and the result was that at first there was an 
incontinence of urine, and a very slight leakage, both of which 
soon ceased entirely.* For some months she was well, but un- 
fortunately she again became pregnant, and after her next labor 

*Vide, The U. S. Medical and Surgical Journal, Vol. IX., p. 330. 



VESICO-VAGINAL FL>TULJB. 877 

there was a small fistulous opening which caused a return of the 
old symptom. She afterwards came before my private class, when 




Fig. 139. Curved scissors. 

the lesion was identified, but she would not consent to another 
operation. 

Prognosis. — If we except those cases in which there is a depraved 
constitution, or a vicious cachexia, like syphilis or cancer, the 
rule is that all cases of vesico-vaginal fistula are curable. If the 
rent is very large, and the sloughing and loss of tissue has been 
very extensive, the case may not justify an operation. Some of 
them get well spontaneously, others by caustics and the milder 
means, and others still require two, three, or more operations. 
Dr. Thomas makes this remark concerning vaginal cystotomy as 
compared with these fistulae : * 

"It is a curious fact that, when for the relief of chronic cystitis 
a vesico-vaginal fistula is intentionally created by the knife, it is 
difficult to keep it open. In spite of the occasional introduction 
of the sound for this purpose, such openings obstinately heal of 
their own accord, so that it becomes necessary to place a species 
of button or stud in the opening to prevent a result which, under 
these circumstances, is undesirable. This case seems parallel with 
that of perforation of the tympanum, which, being effected by an 
instrument, heals rapidly ; while the closure of an opening, the 
result of disease, is usually impossible." 

Treatment. — The treatment of these uro-genital fistulas divides 




Fig. 140. Bozeman's curved scissors. 

itself into that proper for acute or recent cases, and that which 
is adapted to chronic cases. When a fistula is discovered during 

* A practical treatise on Diseases of Women, by T. Gaillard Thomas, M. D., etc. Fifth 
edition, 1880, p. 237. 



878 THE DISEASES OF WOMEN. 

the lying-in there is nothing to do except to keep the patient 
quiet, in the recumbent posture, to wash out 
the vagina and the bladder with warm calendula 
water, to place a Skene's, or a Sims' catheter in the urethra per- 
manently, if the patient can bear it, and to wait in the hope of a 
spontaneous cure. For at this time there would be an intolerance 
of the suture, nor, under the circumstances could it be so readily 
applied as afterwards. Some French authorities advise the use of 
the serre-fines, but in order to adjust them, the rent must be acces- 
sible, and you will need to be very expert. 




Fig. 141. Bozeman's double curved scissors. 

Outside of the puerperal state many attempts have been made 

to heal these fistulse by the use of caustics, either with or without 

an appliance that was designed to keep the edges of the wound 

in apposition. This mode of treatment seems 

m post-puerperal and begt a( j ap t e d to those small and very minute 

chronic cases. x . . 

fistulas m which there is little or no loss ot sub- 
stance. A shot-hole orifice might thus be healed by the use of 
the nitrate of silver, caustic ammonia, or potas- 
sa, nitric acid, tincture of iodine, the tincture of 
cantharides, sulphuric acid, chromic acid, the acid nitrate of mer- 
cury, or the galvano-cautery. 

In a remarkable monograph upon this mode of treating vesico- 
vaginal fistula, Dr. E. F. Boque gives the details of 204 cases and 
the results obtained.* Of these, in twenty-one cases the size of 
the fistula was from one to six centimetres, in twenty-four from 
one to three fingers could be passed through the orifice, and in a 
still larger number the opening would admit the uterine sound. 
His comparative tables show as good results as were obtained up 
to the year 1875 by the more usual operation that was first prac- 
tised in this country by Dr. Sims. 

* Du traitement des fistules uro-genitales de la femme par la reunion secondaire, etc.. 
par Ed. F. Boque, Paris. 1875, pp. 261. 



VESICO- VAGINAL FISTULA. 



871) 



In the Archives de Tocologie, etc., for May, 1880, you will find 
the record of a most remarkable case of vesico- 
vaginal fistula which had been operated upon 
and closed with silk sutures five times in succession without a 




Fig. 142. A serrated clamp and its mode of application. 

cure, by Dr. Gerassimides of the Faculty of Pisa. He finally 
devised an instrument for holding the edges of the wound securely 
until they had united. Fig. 142 shows the mode of application of 
this serrated clamp from the vaginal side. 



880 



THE DISEASES OF WOMEN. 



The American 



The usual operation 
for. 



We must not omit to mention that in the repeated operations 
made in this case, the silk and not the silver wire suture was em- 
ployed. 

operation, so styled because it was first elabo- 
rated and applied by Dr. Sims, of New York, is 
the prevalent mode of cure for these, as well as 
for other forms of genital fistulae. The prepar- 
atory treatment consists in the removal of bands and adhesions 
that may have formed, by means of their division and dilatation, 
as in other kinds of anaplastic surgery. For if 
The preparatory treat- th ^ f tissue that is to be operated upon is 

ment. l i 

not free from tension, and tolerant of the suture, 
the result will be a failure. In extreme cases it may happen that 
weeks will be spent in getting rid of these obstacles, by exposing 
them and cutting the bands with the scissors, after which the 
vagina is dilated mechanically with sponge that is covered with 
oiled silk, or with a glass vaginal plug. Meanwhile, the inflamed 
and tender surface of the vagina may be healed as far as possible, 
by soothing applications. 




Pig. 143. Bozeman's position for vesico-vaginal fistulas. 

When we are ready for the operation five indications should be 
kept clearly in mind. (1), to expose the rent, 

Special surgical indi- ^ ^ make Jt ihorouo;hly accessible; (2), to 

freshen its margin as perfectly as possible ; (3), 
to apply and to secure the sutures so as to close the fistulous 
orifice with the greatest accuracy; (4), to drain the bladder while 



VESICOVAGINAL FISTULA. 881 

the wound is healing; and (5), to remove the sutures very 
cautiously in due time. 

The first of these indications is met by placing the patient in 
the Sims', or the prone position upon a proper 

wound ViCW ° f the table or cnair > ancl in a g' oocl light. Some oper- 
ators prefer Bozeman's plan in which (Fig. 143) 
the patient is secured in the knee-chest position by an arrange- 
ment which can be screwed to the table. A Sims speculum is 
then passed and the perineum is retracted. Lateral retraction, by 
Sims depressor (Fig. 144) may also be applied so as to expose the 
affected part more thoroughly. It the rent is high in the anterior 



Fig. 144. Sims' depressor. 

cul-de-sac, or lateral, and not readily accessible, it may be best to 
seize the uterine cervix and bring the womb down to the extent 
of everting the anterior roof of the vagina. If necessary the 
cervix can then be secured by a loop, and given in charge of an 
assistant. 

To freshen the edges of the wound is always a delicate, and 
sometimes a difficult task. It must be done as 

g iIi VifyinB thG ^ freel y and as thoroughly as possible, but from 
the vaginal side only. The vesical mucous mem- 
brane should not be cut, or pricked, or injured in any way. Simon, 
of Heidelberg, intentionally included the bladder, but it is not 




Fig. 145. Emmet's double-curved scissors. 

safe. Every bit of mucous, or of cicatricial tissue upon the bor- 
ders of the fistula must be removed before we can reasonably hope 
for a good result. The plan which I have found most convenient 
is to secure one lip of the rent at a time with a Sims seizing for- 
ceps (Fig. 149 ) and then to pare the edges with the curved scissors, 



882 



THE DISEASES OF WOMEN. 



(Figs. 145, 146, 147) or with the knife (Fig. 148). The art of 
vivifying the margins and bevelling them properly is acquired 
with practice and care, and when you have made the operation a 
dozen times you will have acquired sufficient dexterity to do it 
well . 




Fig. 146. Bozeman's angular scissors. 

I am fully convinced that Emmet's idea of using the scissors in 
preference to the knife in these cases, because it exercises a kind 
of torsion of the capillaries as we proceed, is the correct one. If 
there is considerable haemorrhage, the hot-w T ater irrigation, as in 
trachelorrhaphy, will arrest it. 




Fig. 147. Emmet's curved scissors. 

The next step is the insertion of the sutures, which should 
always be of silver wire. The whole secret of 
su^ure i s nSerti ° n0fthe passing them properly is to remember that the 
vesical and vaginal mucous membranes are sepa- 
rated by a layer of cellular tissue, and that the needle must pene- 
trate the vaginal side and pass through this intermediate tissue 
without puncturing the bladder. 




=cf 



Fig. 148. Sims' rotary knife. 

Taking a Sims' needle-holder, (Fig. 151,) and one of Sims', of 
Emmet's, or of Hodgen's needles, its point is introduced at a third 



VESICO-VAGINAL FISTUL^E. 



853 



to a quarter, or even half an inch from the margin, is made to pass 
through the freshened edges and across the fistulous orifice, so as 
to emerge at the same distance from the opposite lip of the wound. 



Fig. 149. Sims' seizing forceps. 

The suture is drawn through, the border being steadied by this 
little fork ( Fig. 152) , and cut oft' at the proper distance. (Fig. 153 ) 
The first of these is passed at the upper end of the fistula and 
the others in succession, from above downwards, until all are in 
position. Then, before twisting them down and closing the 
wound, the bladder and the vagina should be carefully washed 
and cleansed of blood-clots and of all foreign substances. 




Fig. 150 Tubular needles. 

Here is an expensive case of tubular needles which I brought 
from Mathieu, m Paris, that are designed to pass the silver wire 
directly by means of a reel in the handle. I have tried them sev- 
eral times, with the result of satisfying myself that they are 



884 



THE DISEASES OF AVOMEN, 



of great service when the vagina is narrow and the rent is high 
and difficult of access. The varying curves of the needles fit 
them for use especially in recto-vaginal fis- 
tulae. 

The careful adjustment of the freshened 

borders may be effected with the fingers and 

by the manipulation of the sutures. It must 

be done slowly and cau- 

Adjustment of the .• -i i i 

lips of the wound. tiously, so as by bringing 
the edges together exter- 
nally to turn their united margin into the 
cavity of the bladder. This not only brings 
the scarified surfaces into close contact, but 
it makes a ridge within the bladder that turns 
the water like the peak of a roof. It is be- 
cause this bit of tailorino;must be water-tiofht 
that you should take the greatest care so to 
twist the sutures as to bring the parts into 
exact apposition, and not to close the mouth 
of either of the ureters. Asa rule we always 
begin by twisting those sutures Avhich are 
nearest to the vulvar outlet, but they must 
not be drawn too tightly. 

Concerning the best method of securing 
these sutures, when they have been carefully 
fig. i5i» Sims' needie-hoi- twisted, there are various opinions. The 
der - simplest plan is to cut them off and bend 

them at a right angle with the wound, as you have seen me do 
after an ovariotomy. Some prefer to pass a per- 
forated shot over the wire and then to com- 
press it firmly; and others use a thin disk of 
perforated lead, which is known as Bozeman's button (Fig. 154), 
and which can be trimmed to suit special cases. Sometimes both 
are used together. (Fig. 154). 

In the majority of cases, since the principle is the same, there 
is no compensation for the extra trouble of fitting and adjusting a 
Bozeman's button, or anybody's clamp. The interrupted suture is 
sufficient. 

In order to prevent an accumulation of urine, which would strain 




Tightening the sut 
ures. 



VESICOVAGINAL FISTULA. 



885 



Vesical drainage. 



f 



\ 



\ 



1 



the wound, interfere with its union, and give rise to pain and 
suffering, the bladder must be drained, at least 
for the first forty-eight hours. If the urethra 
will tolerate it therefore, a Sims improved, or a Skene's self-retain- 
ing catheter (Fig. 69) may be passed and allowed (D 
to remain in position. Unfortunately, the cases (/ 
in wnich the lesion is at the bas-fond ot the blad- 
der, are those in which the instrument is not very 
well borne, and you will need to remove it occa- 
sionally, or perhaps to take it away altogether. 
In two of my cases I found the flexible rubber 
catheter to answer the purpose. The catheter 
will need to be removed now and then in order to 
cleanse it, and it may be necessary to draw off 
the urine at regular intervals during the first fort- 
night. 

The sutures should be carefully removed on the 
ninth or the tenth day. The ease with which this 
maybe accomplished will depend upon circum- FlG 152- Thewiread 
stances. If the rent is high, or the parts are i^hook^' an< 
tumefied and the sutures are buried out of sight, it may be very 
difficult. It is sometimes necessary to seize 
the neck of the womb and 
draw it down again. If 
the wire is not readily ac- 
cessible, you will have to take the blunt hook 
(Fig. 152) and fish up the loop so that you 
may pass one blade of the scissors through 
it as shown in Fig. 1 56. Care should be taken 
to straighten the cut end of the suture before 
turning it out, lest you 
tear the tissues. 
You should not be dis- 
couraged if, upon the removal of the sutures 
there is a slight leakage of urine into the vagina. In very bad 
eises this is likely to happen, and may be only temporary. But 
sometimes a small orifice may remain, and this w r ili need to be 
treated by a subsequent operation. 

It is commonly supposed that the operation which I have just 



and 




Removal of the su- 
tures. 



Caution, and encour- 
agement, 



Fig. 153. The sutures 
x position. 



THE DISEASES OF WOMEN. 




Fig. 154 

button sutures 



Bozeman's 



described is tree from danger, even where it is not successful. Our 
American authors are almost silent upon this 

The dangers of the . 

operation. point. Hie fact is that there is no other opera- 

tion which belongs to anaplastic surgery that is 

so dangerous as this one. In a remarkable memoir upon this sub- 
ject, contained in the Annates de Gynecologie 
for January 1877, Doctor Vemeuil treats this 
subject very thoroughly. He says: 

"t am pursuaded that the newer methods of 
operating are less dangerous than the old, first, 
because ot their usual success at the first trial, 
the repeated operations that were once necessary 
are not called for; and also because in the 
different steps of the operation the tissues are better managed, 
and, as a rule, the preparatory incis- 
ions, dilatation, etc., are dispensed with. 
In spite of all this however, at least il 
I may judge by my own experience, 
the mortality is still pretty large. In- 
deed, in my- unfortunate cases I do not 
think that I have committed any great 
surgical error either before, during, or 
after the operation, and yet I have lost 
five women in about eighty operations ! 
Two others have threatened to die, one 
of erysipelas, and the other of embol- 
ism land several have been very ill with 
pelvic troubles, but they have finally recovered." 

Fatal results have also been recorded in consequence of second- 
ary haemorrhage, traumatic fever, pelvi-peritonitis, cystitis, al- 
buminous nephritis, hydronephrosis, and uraemia. In the journal 
just referred to for the following month, page 129, M. le Dr. 
Puech gives the statistics of 229 cases which had been operated 
upon by various physicians with a loss of thirteen, or one in 
every seventeen cases. 

The practical inference is therefore, that, even in the most 
promising cases, this operation should not be undertaken without 
care in the selection of subjects, nor yet without qualifying our 
prognosis with reference to a possibly fatal result. 

Beside the operation which we have consid- 

Eiytropiasty ^^ ^^ . g ft form of ves i co _vagmal anaplasty 

that is very rarely practised in our day, which consists in closing 




VES1CO- VAGINAL FISTULJE. 



887 



the fistula by means of a flap that has been dissected from the pos- 
terior wall of the vagina, the vulva, or the buttock, and stitched 
into the fistulous orifice. 

Another expedient consists in the closure of the 
vagina, as in the extreme cases of procidentia of 
the uterus spoken of in Lecture XXXVIII. 



Episiorrhaphy. 




Fig. 156. Introduction ^f the sutures. 
KECTO-VAGINAL FISTULA. 

In this form of fistula the recto-vaginal septum is open and 
permits the escape of gas and of faces from the rectum into the 
vagina. A good idea of its most common form is given in Fig. 
137. The extent and location of the orifice varies. It may be 
small enough merely to admit the point of a probe, or large 
enough to reach from the posterior cul-de-sac to, and even through 



888 



THE DISEASES OF WOMEN. 



the sphincter and and the perineum. In some cases it is so high 

as to be found with difficulty, but oftener it is within easy reach. 

Causes. — For the most part the causes are the same as those 

of vesico-vaginal fistula, — protracted labor, pressure from an im- 




Fig. 157. Straight scissors. 

pacted head, traumatism from manual interference, an abuse of 
the forceps, or, more frequently, an unwarrantable or unavoid- 
able delay in using them; the wearing of mal-adjusted, broken, 
or decayed and decomposing pessaries, abscesses, excessive and 




Fig. 158. Sims' knife-h lder. 

misapplied cauterization, the ulceration caused by hardened fseces, 
stricture of the rectum, penetrating wounds of the vagina, and 
syphilitic and cancerous ulceration. 

Physical signs. — The objective signs of this disagreeable infirmity 
consist in the passage of faecal matter and of ffatus into the 



Fig. 159. Notts' double tenaculum. 

vagina. If the rent involves a rupture of the sphincter ani and 
of the perineal delta, as my friend Dorion termed it, the rectum 
and the vagina have a common outlet, and the patient becomes a 
monotreme. 

The physical examination may be made with the patient lying 
upon her back. The hips should be brought squarely to the edge 
ot the table, and a Sims speculum passed in a reverse way from 



RECTO- VAGINAL FISTULA, 



m 



that in which it is usually employed. With this the anterior 
wall of the vagina is lifted, and the recto-vaginal 

The physical exam- . " . ■.-..., 

ination. septum falls into view. Ihe location and limits 

of the rent may then be known by pass- 
ing the finger into the rectum. If the fissure is small and high 
up toward the roof of the vagina, it may be best to turn the 




Fig. 160. Nott's depressor. 

patient upon her left side. In either case the margins of the 
opening are less likely to be inflamed and excoriated than in the 
ease of vesico-vaginal fistulas. 

Prognosis. — Contrary to what you may have supposed a larger 
proportion of cases of vesico-vaginal fistulas are curable than of 
those now under consideration. Indeed, fecal fistulas of all kinds 



Fig. 161. Sims' uterine tenaculum. 

are rebellious to treatment, and we must not promise too much 
for any of them. I have long been satisfied that better results 
will be obtained in these cases when we realize that a single 
mode of operation is not suited to all of them indiscriminately. 
It is a fallacy to suppose that because a general surgeon has been 




Fig. 162. Bozeman's wire adjuster. 

successful in the ordinary line of his work, he must, therefore, 
be skilful and successful in these cases also. Briefly, the prog- 
nosis will vary with the kind and degree of the lesion, the general 
condition of the patient, the nearness or remoteness of the puer- 
peral state, the mode of operation that is employed, the neces- 
sity for its repetition, and the dexterity and the special experience 
of the operator. 

The Surgical Treatment. — The simplest mode of operation con- 
sists in freshening the edges of the orifice upon the vaginal side, 



890 THE DISEASES OF WOMEN. 

in drawing them together accurately by interrupted silver sutures, 
in twisting these sutures, in passing the perfor- 

The usual operation. ,-,■■,,-, • , i ^ i 

ated shot and compressing them, the same as 
in vesico-vaginal fistulse. In this case, therefore, you will need 
the same instruments that I have already advised in the former 
part of this lecture. The freshening may usually be done with a 
pair of straight scissors (Fig. 157). If the fistula is far away, 
however, you may need to use a Sims knife-holder and adjustable 
blade, (Fig. 15b ) instead of these or the curved scissors. For hold- 
ing the margins firmly, a Notts' depressor (Fig. 160), or double 
tenaculum (Fig. 159), or a Sims uterine tenaculum (Fig. 161) 
may be necessary. In vivifying the margins, as well as in passing 
the needle, the introduction of a rubber ball, like a Gariel's air- 
pessary, Avhich can be passed into the rectum behind the fistula 
and inflated, will sometimes expedite the operation. 

I have found Bozeman's wire-adjustor of real service in twist- 
ing the sutures closely in some cases of recto-vaginal fistulae and I 
much prefer to secure the wires with perforated shot that can be 
compressed with these forceps. (Fig. 163). 




Fig. 163. Shot compressor. 

In the after-treatment, it is really a question whether the old 
practice of keeping the bowels bound does not 

The after-treatment. , , 7", i t»t i 

do more harm than good. My early experience 
convinced me that the passage ot hardened fecal masses into the 
rectum after a period of forced constipation was very likely to> 
interfere with a good result; and I consequently adopted the 
practice of keeping the bowels in a soluble state by the use of 
laxative food and fruits, and by the occasional prescription of nux 
vomica, plumbum, or collinsonia. Vaginal injections of warm 
water with the tincture of calendula may be used daily. The 
sutures may be removed in eight or ten days, and the patient 
allowed to take moderate exercise after the second week. To 



EECTO- VAGINAL FISTULA. 



891 



admit of the escape of flatus, and to prevent tenesmus a rectal 
tube should be worn for some days. 

Another mode of operation is to bevel the edges of the fistula, 

and to sew the wound on the rectal instead of 

Newer modes of ope- the inal sur f ace . This is easily accomplished 

ration. & . 

by stretching the sphincter with the two thumbs 
(as should be clone in all modes of operating,) and the introduc= 
tion of the speculum through it into the bowel. In order to 
avoid the trouble and pain of removing the rectal 
sutures, Dr. Goodell prefers that they should be of 
fine gut. 

An ingenious method consists in splitting the 
margin of the fistula all around, and afterwards 
uniting them by two sets of sutures, one of which 
is in- the vagina and the other in the rectum. 

In another plan of operation, which is highly 
recommended by Dr. Goodell, 

" A shallow cut is made around the vaginal mouth 
of the fistula, about half an inch away from it, and 
the mucous membrane dissected up to its rim in a 
frill. This is n^xt inverted and pushed into the 
rectum through the opening, which is now closed 
by rectal and vaginal stitches — the former uniting 
the raw surfaces of the frill, the latter the raw strip 
around the vaginal rim of the fistula. Should the 
opening into the rectum be too high up to be 
reached, the rectal stitches can be passed per vag~ 
inam in the following manner: Before the mu- 
cous frill has been inverted, metallic sutures are 
passed through its edges, each end of each one 
entering the raw surface and emerging on the mu- 
cous surface. The free ends of the wires are next 
secured temporarily by twisting them over a per- Fig. 164. Agnew's 
forated shot. After all these sutures have been adjuster, 
passed, the shot are pushed through the fistula into the rec- 
tum and out through the anus, and the frill is inverted ty traction 
on them. The sh<~>t are then run up one by one to the rectal 
wound and clamped, and the operation is completed by sewing up 
the vaginal wound." 




LECTUKE LIV. 

LACERATIONS OF THE VULVA AND OF THE PERINEUM — PERINEOR- 
RHAPHY. 

These lacerations are often confounded. The anatomy of the vulvar orifice. Lacera- 
tions of the fourchette. Anatomy of the perim um. The peineal body. Physiol- 
ogy of the perineum. Case. -Varieties of perineal laceration. Frequency of do. 
Symptoms. Treatment. The primary and secondary operations. 

In the practical study of lacerations of the perineum we shall 

avoid contusion it we are careful not to confound those of the 

perineum proper with those of the vulvar or- 

Theseiacerationsoften ifice> p although these lesions are usually 

confounded. ... 

described as identical, they are not really so; 
and much trouble has been occasioned by the fact that the anat- 
omy of these parts has not been separately considered and studied 
by gynaecologists. 

The peculiarities of structure of the vulvar orifice are- the raphe, 
or the junction of the vaginal mucous membrane with the integu- 
ment; the fourchette, and the form and direc- 

Anetomy of the vul- . r , , . . , . , 

var orifice. tion ol the sphincter vagmse muscle, which sur- 

rounds the external orifice of the vagina, and 
which is attached posteriorly to the central portion of the perin- 
eum, where it mixes with the transversalis and the sphincter ani 
muscles. These structures guard the vaginal orifice and permit of 
its distensibility and dilatability, which qualities are essential to a 
safe and natural labor. 

The sphincter vaginae is an orbicular muscle, which is more easily 
broken than you would suppose, if the force that is applied is not 
in the direction of the axis of the vagina. Hence, in very rapid 
labors, when the presenting part is driven through the vulvar 
outlet there is not sufficient time for adaptation, and the sudden 
extrusion results in a rupture of the sphincter. This rupture 
may occur laterally and involve the labia, or superiorly, through 
the anterior commissure of the vulva or the nymphae, where it 

892 



LACERATION OF THE PERINEUM. 



893 



Laceration of the 
fourchette. 



bleeds freely; but more frequently it takes place at the posterior 
commissure of the vulva. 

In primiparse the fourchette is almost always torn in labor, but, 
if the deeper structures are not involved, the case is not one of 
laceration of the perineum. So long as the 
wound is limited to the vulvo-vaginal orifice it 
is really as distinct from a case of ruptured per- 
ineum as it is from one of laceration of. the cervix uteri. The 
fact is that the co-existence of rigidity of the os uteri with what 
is usually styled a ruptured perineum in labor is a mistake; 
a practical hint. for tne external part which is unyielding is 

the vulvar orifice, and not the perineum. The 
careful obstetrician will tell you that, if labor is retarded by an 
undilatable os-uteri, the presenting part is sure to be arrested in a 




Fig. 165. The form, location and relations of the perineal body. 

similar way at the vulva. And the gynaecologist will tell you that 
the resulting lacerations ot the cervix and of the fourchette tally 
exactly with this state of things. 

The peculiarities of the perineum concern the form, the posi- 
tion, the structure, and the relations of what 
mtuT mJ ° f ^ Per " has been a P% termed the perineal body. This 
is a triangular muscular structure which is lo- 
cated between the orifice of the vagina and that of the rectum. 



894 THE DISEASES OF WOMEN. 

Its broadest part is at the integument, or along its cutaneous bor- 
der, and its apex merges into the recto-vaginal septum. So you 
observe in this model (Fig. 165), its anterior 

The perineal body. . . v . ' 

margin is along the posterior wall of the vagina, 
and its posterior border is anterior to the rectum. It lies be- 
tween the two, and its purpose is to prevent a prolapse of the 
bowel into the vagina, as well as a descent of the vagina itself, 
and also of the uterus and the bladder. 

The physiology of the perineum is peculiarly interesting. It 
may not have occurred to you, and you may not have read in your 
text-books, that the changes which take place 
th?p e errne y um 10 ^ ° f in the Perineal body during gestation, and after 
delivery are as pronounced in their way as are 
those which are proper to the mammary gland, the heart, the 
liver, or even to the uterus. Whatever interferes with the devel- 
opment of this inverted keystone during pregnancy will predis- 
pose it to traumatic injuries during labor; and whatever arrests 
its puerperal involution will prevent the reparative process after- 
wards. There are cases of laceration of the perineum which re- 
sult from the imperfect development of these structures, and from 
their forced expansion during labor, which, strictly speaking, are 
due to an organic defect, for which no one is to blame, and for 
which there is no known prophylaxis. 

Observe that, in order that we may have a case of lacerated 
perineum, this perineal body must be torn, or split, and the rent 
must extend into its structure, or perhaps through it, to the 
recto-vaginal septum. The rupture may be partial or complete, 
and it may or it may not involve the sphincter ani, and the sphinc- 
ter vaginae. In rare cases the perineum' is perforated, and the 
child has been extruded without injury to either of these sphinc- 
ters. When the laceration has begun at the fourchette and ex- 
tended to the sphincter ani, both the vulvar orifice and the perineal 
body have been stretched and torn; and when it has involved the 
recto-vaginal septum, the case is complicated with a recto-vaginal 
fistula. One of the classes has recently seen me operate upon a 
very marked case of this kind in my sub-clinic. 

Causes. — Premature delivery, tedious, impracticable and in- 
strumental labor, the too rapid extrusion of the foetal head, puer- 
peral convulsions, the delivery of the shoulders, dry births, 



LACERATION OF THE PERINEUM. 895 

irregular, vertex and face presentations, and version, are the 
most common causes of this accident. It is more likely to result 
in first than in subsequent labors; and there is a tradition that 
women who have their first children late hi life are especially 
liable to it. Laceration of the perineum may also arise from a 
direct wound, and from the careless delivery of uterine tumors. 

Case. — I once had a case in my clinic in which the patient was 
brought before the class for the removal of an enormous fibroid 
which had escaped from the os uteri, and which filled the pelvis 
completely. It was severed by a strong copper wire i . the 
ecraseur, but the wire broke twice before it was finally detached. 
When I removed the instrument I found that the catch on the 
back side of the staff had split the perineum all the way down to 
its cutaneous border! The tumor, which afterwards weighed six 
pounds, was so spherical that it could not be delivered by the 
usual means. I then applied the obstetric forceps, but it was too 
dense for compression and I was forced to desist. My only re- 
maining resource was to cut it in pieces and to take it away in 
sections, which was carefully and successfully clone. The patient 
had been so long under the influence of the anaesthetic, and was 
so very weak and anaemic from the fearful menorrhagia to which 
she had been subject, that it was not safe to make the primary 
operation for the cure of the lacerated perineum. Six months 
later I made the operation of perineorrhaphy upon that woman 
in this amphitheatre, with an excellent result. The last heard of 
her, for she was a farmer's wife in Wisconsin, she was riding 
upon a reaping machine in the harvest field. 

Varieties. — The three varieties, that are usually described are 
(1), a shallow superficial rent, extending through the fourchette, 
and scarcely touching the perineal body; (2), a rupture of the 
perineum proper as far as the external sphincter ani, and (3), a 
laceration that extends from the posterior commissure of the 
vulva through the sphincter and into the bowel. For reasons 
that I have given you the first of these should properly be re- 
garded as a laceration of the vulvar orifice and not of the peri- 
neum. They are the kinds of laceration which often heal spon- 
taneously. 

Frequency. — What I have said of the relative frequency of 

lacerations of the cervix uteri is quite as true 
thle i^ons 10 ° k f ° r of ™ lvar and perineal lacerations. The mere 

fact that physicians and obstetricians have often 
overlooked them, does not disprove their existence. In recent 



896 1HE DISEASES OF WOMEN. 

cases we cannot be certain of their location or extent without a 
careful examination after the labor. This examination should be 
made with a competent assistant, a sponge and some warm water, 
and by means of a candle or a lamp. For the touch alone, no 
matter how educated or experienced, cannot decide this question. 

It is not always practicable or expedient to inspect the teo-u- 
mentary perineum at the close of labor; but the fact remains 
that these lesions within or through the vulva, and into the peri- 
neum more or less deeply, do really exist in a considerable share 
of cases. What that proportion is I cannot say. Perhaps in one 
labor out of four or five occurring in primipara they could be 
found if we should look for them very carefully. For the sake of 
your own reputation, as well as for the cure of your patients, I 
recommend you to examine these cases for yourselves, and not ta 
trust to the ipse dixit of the nurse, or to your own post-partum 
impressions. 

It is not unusual for physicians to insist that, in all their ob- 
stetric experience, not a single woman has been "torn;" and 
that, with the proper care, such a mishap may always be avoided. 
Butt, since we cannot vouch for the integrity of the perineal and 
vulvar tissues, and cannot always control the direction or the 
degree of the forces that are necessary to effect delivery, this 
claim is unwarranted. Lacerations on the vaginal surface of the 
fourchette especially, are the rule and not the exception. 

Symptoms. — The physical signs of the laceration are easily made 
out. By placing the patient on her back and separating and flex- 
ing the thighs, the rent is easily exposed. The labia may be 
stretched apart and the posterior commissure found to extend to- 
ward the anus. If the case has become chronic, the pelvic organs 
will be prolapsed, and the degree of the cystocele and the recto- 
cele will be in proportion to the duration, the extent and the 
depth of the laceration. 

If some time has elapsed since the accident the margins of the 
rent will be cicatrized, and this condition of the surfaces may be 
a source of general ill health. For, while this 
tioTof Ct the°rent CatriZa " heterologous tissue is often harmless, its pre* 
ence in delicate, slender and nervous women 
especially, is likely to give rise to a series of reflex disorders that 
are impossible of cure, except by an operation for its removal. 



LACERATION OF THE PERINEUM. 897 

Treatment. — The treatment naturally divides itself into that 

proper for acute and for chronic cases. If you are called to a case 

in which not more than ten or twelve hours have 

The immediate treat- edi j accident, and before the mar- 

ment in recent cases. *■ _ ' 

gins of the wound have healed over, it will be 
a question as to whether you shall stitch it up or not. Some au- 
thorities will tell you that you ought always to resort to the 
suture, and others will insist that it is never necessary. Both are 
right and both are wrong in their extreme views. If the lacera- 
tion does not extend more than from one-third to one-half of the 
depth of the perineum, and if you can depend upon the patient 
and the nurse to obey instructions; if there are epidemic diseases 
in the house or the neighborhood, or if there are other puerperal 
cases under the same roof, you had better not pass the needle 
through the tissues, but keep them in apposition by other means 
until adhesive inflammation sets in. 

In such cases my own practice has been to cleanse the parts thor- 
oughly with warm calendula water, carefully removing all clots, 
bits of fat and shreds, and then to mould the edges as carefully as 
possible so as to bring the tegumcntary perineum into its proper 
position. Then I place a firm compress that has been moistened 
with a mixture of equal parts of calendula or of hamamelis, 
glycerine and warm water, against the perineum, and while the 
limbs are flexed, put two or three adhesive straps across the but- 
tocks to keep the compress in position. This adjustment of the 
parts should be made with the patient lying upon her side. The 
compress may be freshened two or three times in twenty-four 
hours, and weak injections of calendula water may be given per 
vaginam once or twice daily until the wound is healed. The 
knees should be tied together, but not tightly, for the first fort} T - 
eight hours. The bowels should be let alone, the patient should 
lie upon her side, and the urine should betaken with the catheter. 
I have practised this simple plan of treatment for almost thirty 
years, and am confident that in a great majority of cases it is quite 

sufficient. It mav sometimes be supplemented 

The use of serre-fines. . . , 

by the use of serre-nnes, which, if they are of 
the right kind and are properly adjusted, will keep the edges of 
the wound from slipping before they have healed. If the patient 
is very nervous and apprehensive, she need not know that they 



898 THE DISEASES OF WOMEN, 

have been applied, and the compress can be used at the same time, 

The primary operation is not difficult unless the wound has 

passed through the sphincter ani, or involved the recto-vaginal 

septum, in which case it will be necessary to 

The primary operation. . . .,■ .. , -. 

administer an anaesthetic and to proceed as we 
do outside of the puerperal state. Under these circumstances the 
operation is really contra-indicated, because of the exhausted con- 
dition at the close of labor, and because of the mischievous effect 
of the lochia in so extensive a wound. 

When, however, the degree of the laceration does not include 
the sphincter ani, or the septum above the apex of the perineal 
body, the wire sutures may be passed from the cutaneous surface 
and twisted as in the usual operation of perineorrhaphy. 

The secondary operation, for chronic cases, ought not to be 

made until at least three months have elapsed from the date of 

the delivery, and six are better than three in 

The secondary opera- m0gt ^^ The old rule wag to w ^ f ^-j tfae 

tion. 

child was weaned. The preparatory treatment 
for perineorrhaphy is to allay any existing local inflammation of 
the parts, to have the bowels thoroughly opened a day or two be- 
forehand and the patient in a good general condition. In a few 
cases I have found it necessary first to obtain the control of a 
copious leucorrhceal discharge before operating, lest the flow 
should interfere with the union of the parts. 

The operation is comprised in three steps: (1.) The freshening 

of the perineal angles; (2) the introduction of the sutures, and 

(3) the closure of the wound by the tightening 

The freshening pro- of the sutures> The vivifying process is the 

cess. m . 

same as that described for vesico- and recto-va- 
ginal fistulae, except that a much larger surface is freshened. In 
removing the cicatricial tissue care should be taken to avoid injur- 
ing the rectal mucous membrane. The patient being placed in 
the lithotomy position, with the nates drawn to the edge of the 
table in a strong light, and the anterior vagina lifted with a Sims' 
speculum, it is well to make an incision along the border of the 
space that is to be freshened, so as to mark the outline of the per- 
ineal body. When this is done on both sides, the membrane that 
covers the wound is dissected off carefully with the knife, or bet- 
ter still with the scissors, and no portion of it is allowed to re- 



LACERATION OF THE PERINEUM. 899 

main. If the laceration has extended to the septum above the 
perineal body, its margins will also need to be freshened, the same 







"Fig. 166. Surface denuded in complete perinea] rupture and first two sutures in posi- 
tion (Thomas). 

as in recto-vaginal fistula. Fig. 166 represents the outline of this 
newly-made wound, in a case of complete rupture through the 
anal sphincter. 

While these lateral triangles are being pared of their cicatri- 
cial tissue if there is much haemorrhage, it should be controlled 
by the use of hot water, or, if there are spouting arteries, by 
Pean's hemostatic forceps. The index finger of the left hand 
should be passed into the anus to assist in freshening the surface 
at the bottom of the furrow which separates the two halves of the 
perineal body. 

The second step of the operation concerns the introduction of 

the interrupted sutures. Most authors prefer 
smure P s aSSaffe ° fthe the silver wire, but they are not agreed upon 

the propriety of passing them through either of 
the three surfaces of the perineal body exclusively. Some prefer 
to introduce them from the cutaneous border only, others from 
the cutaneous and vaginal surfaces, and a few on the rectal side 
also. Here is a variety of needles that have been devised for the 
passage of the perineal sutures. I prefer a straight needle, 

57 



900 



THE DISEASES OF WOMEN. 



about one and a half to two inches in length, the point of which 
has been ground like a glover's needle. It should be of the best 
material and not too small. For the deep stitch in a complete lac- 
eration I use Pean's curved needle, which is something like Ash- 
ton's (Figs. 170 and 168) and which, having an eye in its point, 
allows it to be threaded after it has been passed. Dr. Bantock's 
method of suturing the perineal wound has a wide range in differ- 
ent cases and degrees of operation. It is well shown in Figs. 1-SL 




Pig. 167. Lacerated perineal surface denuded, and the sutures in position (Thomas). 

Peaslee's needles (Fig. 170), are better than Skene's (Fig. 171), 
being narrow and therefore less likely to cut the perineal vessels. 
Skene's needle is weakened at the point by the size of the eye, 
which cuts it half off. I had one of them break while being 
passed and was obliged to dissect out the fragment. 

A new needle with a holder which is very useful m this and 
kindred operations is Eeverdin's (Fig. 169). The careful intro- 
duction of the sutures is very important. Their course may be 
directed by the finger in the rectum. In case the sphincter is torn 
the two lower stitches should be hidden in the recto-vaginal sep- 
tum. All the sutures should be passed and the wound thoroughly 
cleansed before any of them are tightened. In twisting them we 
always begin with the lower one and are very careful to adjust the 
lips of the wound most accurately. For this purpose it may be neces- 
sary to insert a few superficial sutures, which should be of cat-gut. 



LACERATION OF THE PERINEUM. 



901 



Some authors, notably Bantock, use the silk-worm gut instead 
of the wire sutures. Others employ the carbolized silk, but the 
ware is preferable. The mode of securing the silver wire in these 
eases is to twist and bend the sutures at right angles. The perfor- 
ated shot and the bit of tubing through which they are sometimes 
passed are of no especial advantage. 




Fig. 168. Pean's curved needle. 

The after-treatment consists in tying the knees together with a 
roller and a compress between them; in having the urine drawn 
every four or five hours for the first day and night, after which it 
can be voided naturally; in limiting the patient's diet to nourish- 
ing soups and broths, and semi-solids; in keeping the bowels in a 
laxative condition by the use of small quantities of saline waters, 
to be repeated every alternate day; and having the patient's posi- 
tion changed from side to side. I think it very important to 
abstain from the use of washes and injections during the first 




Fig. 169. Reverdin's needle. 

thirty-six hours, after which the vagina may be gently cleansed by 
an injection of calendula, glycerine and warm water. This should 
be repeated every morning and evening until after the sutures 
have been removed. After the first forty-eight hours the patient 
is apt to complain of a drawing, burning and smarting along the 
line of the. wound. This may be relieved by the direct application, 
over the wires, of a compress, which has been soaked in equal 
parts of the tincture of calendula and of glycerine. 

On the eighth or tenth day, unless she has menstruated mean- 
while, the sutures may be cut and removed in 
the same manner as after the operation for ves- 
icovaginal fistula. 

The result will be successful providing the patient is not scrof- 
ulous, or syphilitic, or the victim of a dyscrasia which has under- 
mined her reparative forces, and providing the operation has been 



Removal of sutures. 



902 



THE DISEASES OF WOMEN. 



properly made and she has had the proper care in the after-treat- 
ment. In old cases in which the perineal body is either absent or 
atrophied, the best result that can be expected or promised is a 
recovery of the control of the sphincter ani. 





Fig. 1. (Bantock). Fig. 2. (Bantock). 

LAWSON TAIT'S METHOD OF PERINEORRHAPHY. 

There was much force in the remark of Doleris in one of his 
recent clinics that he never made a perineorrhaphy twice alike* 
Either he used the continuous suture or did something different 
from what he had practised before. The original operation, as 
made by Brooke and Baker Brown has been variously modified, 




Fig. 170. Ashton's needle for ruptured perineum. 

like the old obstetric forceps, without material improvement. The 
only exception to this rule is that of Lawson Tait, which, in many 
respects is a decided improvement on the old, or the "butterfly'' 
method. It is particularly suited to the complete laceration which 
extends to a greater or less distance through the recto-vaginal sep- 
tum, and to those in which the integrity of the perineum is sorely- 
impaired. 



LACERATION OF THE PERINEUM. 



903 



The essential features of this operation are that there is no sac- 
rifice of tissue in the freshening process. Instead of paring, or 
dissecting off the edges of the wound to make the necessary flaps, 
the raw surfaces are obtained by splitting the tissues. The cut- 
ting is done in the direction of the original cicatrix, and the sur- 
faces which are to be opposed can be made as wide as the operator 
chooses. The sutures, which may be of raw silk or of other 




Fig. 171. Peaslee's perineal needle 

material, are so placed that two of the flaps are turned into the 
rectum and two into the vagina. The septal stitches must be care- 
fully placed or a fistula may result. Of the perineal stitches there 
should be at least three and usually four, and they should be intro- 
duced along the margin of the integument and not beyond it. 
They should emerge, or cross the chasm, at the line which separ- 
ates the flaps. 



Fig. 172. Skene's needle for ruptured perineum. 

I have frequently made this operation both in hospital and 
private practice, and am persuaded of its adaptation to some of 
the worst cases that come under the eye of the gynecologist. 
Indeed it has never failed in my hands to bring the desired relief. 
The following case is one in which it was entirely successful in a 
woman who had suffered a complete laceration of the perineum for 
more than thirty years. 

Case. — Mrs. , aged fifty-five, was sent to the Hahnemann 

Hospital by Dr. W. H. Gibbon, of Chariton, Iowa. She had had 
eight children, the eldest of which was thirty-three, and the 
youngest twenty years old. Her first labor was a footling case, 
and the child was born at the end of four days and nights of labor 
under the direction, or the misdirection, of a country midwife. 
During the last two days of this prolonged labor the patient was 
in an unconscious condition. The delivery was finally accom- 
plished by pulling the child forcibly away. The consequence was 
that the perineum suffered a complete rupture, it being torn 



904 THE DISEASES OF WOMEN. 

through the sphincter, and through the recto-vaginal septum to 
the extent of two inches or more. 

Since that time she had had seven more children, each of the 
labors lasting from two to three days and nights. In the whole 
thirty-three years she had had absolutely no control over the 
escape of the foeces, or of flatus from the bowel. 

The operation was set for October 6, 1881. The patient was put 
under the influence of ether, and Class No. 2 was admitted to the 
operating room. 

There were also present Prof. Comstock, of St. Louis; Dr. H. 
N. Keener, of Princeton, and Drs. Dewey, Hislop and Reynolds. 
On careful examination the perineal tissues were so atrophied and 
shrunken that the perineal body could not be found. The lacera- 
tion was A. shaped, and its margins were of the same thickness 
from the apex in the recto-vaginal septum to the base of the wound. 
Consequently there was no surface which could be freshened as in 
the usual mode of making the operation of perineorrhaphy; and 
the retraction s of the parts forbade the removal of tissue, which 
could not be spared in bringing the lips of the wound together. 

Under these circumstances I determined to perform Lawson 
Tait's operation as the only expedient which promised a successful 
result. The incision was made very carefully and freely; the hem- 
orrhage was controlled by hot water. The quadruple suture was 
passed with Mathieu's tubular needle; the rectal and vaginal flaps 
were adjusted carefully; a flexible catheter was left in the anus, 
and the patient put carefully to bed with the knees tied in the 
usual way. 

The rectum and the vagina were washed out each day by small 
injections of tepid water, containing a little carbolic acid and cal- 
endula. The diet was laxative but nourishing, and no effort was 
made to lock the bowels. Portions of soft, faecal matter were dis- 
charged with the injections occasionally; but the nurse observed 
that from the first no part of the injection ever passed through the 
wound from the rectum into the vagina, or vice versa. The urine 
was regularly drawn with a flexible catheter. The sutures were 
removed on the twelfth day, when, upon passing my finger into 
the anus, the sphincter grasped it firmly. The patient stated very 
frankly that for the first time in thirty-three years, she had been 
able to control the escape of flatus from the bowel, and the natural 
sensation of the parts had returned. Two days later the colon had 
been emptied by thorough enemata, and the patient felt so well 
that she wanted to go home. 

October 27, just three weeks from the date of the operation, she 
was discharged cured, and left the hospital for her home in Mis- 
souri. 



LECTUKE LY. 

THE PATHOLOGY OF OVARIAN TUMOR©. 

Tarieties. 1. Ovarian cysts: Morbid Anatomy of ; cyst-contents; the ovarian cell; Etiology: — 
Clinical history of; Symptoms; the subjective signs; adhesions; the physical signs, inspec- 
tion, mensuration, palpation, percussion and auscultation. 2. Dermoid cysts of the ovary : 
Morbid Anatomy of; Etiology of; Diagnosis and Treatment. 3. Fibroid tumors of the 
ovary ; their pathology and clinical history. 

There are four general varieties of ovarian tumors ; ( 1 ) ovarian 
cysts, (2) dermoid cysts of the ovary, (3) fibroid 
Varieties. tumors, and (4) malignant tumors. The first 

three are usually benign, and consist of an extra- 
ordinary growth of the proper ovarian tissues; the last is malig- 
nant, and arises from cancerous deposition and degeneration. 

I. OVARIAN CYSTS. 

1. Morbid Anatomy. — Ovarian cysts are single or multiple, sim- 
ple or compound. A monocyst is a single sac, and a unilocular 
tumor of the ovary is a one-lobed affair. Where there are two or 
more cysts the growth is multilocular. When the added cysts 
grow and multiply on the inner surface of the sac the tumor is 
endogenous; and when from its exterior, like sprouts on a potato, 
it is exogenous. The original sac is sometimes styled the parent- 
cyst and the others are the child-cysts. In number there may be 
an hundred or more of these proliferating cysts, whose aggregate 
weight may vary from a few ounces to a hundred and fifty pounds. 
In February, 1878, I removed an ovarian tumor weighing eighty 
pounds, and the patient made a good recovery. 

The thickness and strength of the cyst-wall varies in different 
cases. Single cysts are more apt to be thick and fibrous than are 
those which are multiple; and older ones are usually thinner and 
more fragile than the younger cysts. 

This arises partly from their distention and partly from the cor- 
rosive action of the contained fluid. Hence the danger from the 
rupture of an old, parent-cyst. Sometimes the wall of the sac will 
be thin in one place and thick in another. If its thickness increases 
as time goes on it is probably sarcomatous. 

905 



906 THE DISEASES OF WOMEN. 

The vascular supply to these growths is furnished through the 
fibrous capsule of the cyst. Only their external surface is sup- 
plied with blood vessels. This is a fact of which advantage is 
taken in the enucleation of unilocular cysts. Sometimes the veins 
on the surface of the cysts are large and tortuous, which is usually 
regarded as a sign of their malignancy. 

The character of the fluid contained varies in the different cysts 

which compose the same tumor, and in the same cyst, if it has 

been repeatedly tapped. The oftener it is 

The cyst-contents, emptied the more depraved the quality of the 
fluid. In polycysts, one small sac may contain a. 
clear, amber-colored serum; another, a honey-like fluid; a third, 
blood; a fourth, a stinking pus; a fifth, the brown or chocolate fluid, 
and in others, two or more of these products may be mixed. Some- 
times the contents are so thick and gluey as not to flow at all, a 
condition which belongs to the colloid cyst. 

Ovarian fluids of every description have a common characteristic 
which is that they are of a sticky, glairy or ropy character, and 
more or less viscid and gelatinous. Mehu attributes this peculiar 
quality of the ovarian fluid to the presence of paralbumen. 

When examined chemically this fluid is found to contain albu- 
men, paralbumen and metalbumen. It does not contain fibrin 
unless the ovarian is mixed with ascitic fluid, or unless the cyst 
from which it came is of the dermoid variety. Doran says: "The 
glairiness, or yellowish-gray coloration of ovarian fluid, is a phys- 
ical characteristic, practically sufficient for diagnosis from ascitic 
fluid. Chemical tests for ovarian fluids are not satisfactory, and 
are of a kind unsuitable for the surgeon who cannot keep up more 
than a superficial knowledge of the science of chemistry, nor carry 
spectroscopes and other apparatus about with him ; nor are medico- 
chemical authorities yet agreed upon a perfect test for ovarian 
fluid." So that the proposition once endorsed by Spencer Wells, 
to detect the presence of paralbumen in a suspected fluid by coag- 
ulating its albumen by boiling it, and re-dissolving the coagulum 
by adding double its volume of strong acetic acid and then boiling 
it again, cannot always be relied upon. The specific gravity of 
ovarian fluids varies from 1006 to 1020. 

When you can find it, the recognition of the Drysdale, or granu- 
lar cell in an abdominal fluid that is examined microscopically, is 
strong presumptive evidence of its ovarian origin. But the micro- 



THE PATHOLOGY OF OVAEIAN TUMORS. 907 

chemical properties and the true clinical import of this cell are 
not yet fully determined. It is spherical, some- 
The ovarian cell. times oval, of a yellowish tint, with a very deli- 
cate envelope, which upon the addition of acetic 
or of phosphoric acid, becomes transparent, so that its glistening 
granules are easily seen through the cell wall in the shape of five 
or six bright shining points. It is a little larger than a pus cor- 
puscle, and has the distinguishing peculiarity that the addition 
does not dissolve its granular contents, as it will in case of the 
inflammatory corpuscle of Gluge. 

Drysdale insists that "this granular cell may be distinguished 
from the pus-cell, lymph-corpuscle, the white blood-cell and other 
cells which resemble it, both by the appearance of the cell and 
by its behavior with acetic acid." 

Other authorities are, however, equally emphatic in support of 
the opposite view. Thus Angus McDonald says: "The general 
character of the fluid, with the peculiar cells referred to, can hardly 
lead to a mistake, although it is to be remembered that the cells 
mentioned are merely evidence of rapidly proliferating epithelium, 
and may occasionally be obtained from fluid secreted in such a cav- 
ity as the pleura." Garrigues affirms that, "The large rounded 
cell-masses found in the cyst-fluid, Bennett's large corpuscles, are 
epithelial cells in fatty degeneration; while Bennett's small cor- 
puscle, or Drysdale's granular ovarian cell, is no cell, but the 
nucleus of an epithelial cell in a state of fatty degeneration. There 
is no pathognomonic morphological element in an ovarian fluid." 
And Lawson Tait settles the question for himself and his follow- 
ers by the following characteristic statement: "In fact, I place no 
reliance on the presence or the absence of these cells in a fluid 
removed by tapping, and as I never tap removable tumors at all 
now, I never have any occasion to look for them, or any oppor- 
tunity." 

The microscope also detects pus and blood corpuscles, coloring 
matter, fat globules and cholestrine, which is an almost invariable 
constituent of this fluid. Its proportion is sometimes very small, 
and on account of certain peculiarities that pertain to its crystaliza- 
tion, it may be difficult to find it. Sometimes, however, it is present 
in such a quantity as to form a thin, glistening pellicle on the sur- 
face of the fluid. 

2. Etiology. — While on account of its follicular anatomy there 



908 THE DISEASES OF WOMEN. 

is no other bodily organ which is so liable to cystic degeneration 
as the ovary, it is not always possible to find an adequate cause for 
the existence of these tumors. They occur in women of all classes 
of society, but are most frequent among those whose surroundings 
are unhealthy, whose diet is meagre, and who are exposed to hard- 
ships of various kinds. In quite a share of cases they happen in 
cancerous and tuberculous subjects. Indeed some form of cancer, 
or of phthisis has so frequently developed within a few months, or 
a very few years after I have removed an ovarian cystoma, even 
where such a dyscrasia had not been known or recognized before- 
hand, that I have come to be suspicious of their causative relation. 

Quite a share of these cases can be traced to some local injury. 
One of my patients had a multilocular cyst in consequence of fall- 
ing through the head of a barrel upon which she was standing. 
Another was jammed and injured in the abdomen by a runaway 
horse; and a third was kicked in the left inguinal region by a brute 
of a husband, after which a tumor of this kind soon began to grow. 
In other cases the traumatic cause is a strain from lifting, as in 
carrying coal or water up-stairs, when "something gives way" and 
the trouble with the ovary begins. While it may happen that dif- 
ferent members of the same family shall have ovarian tumors from 
accidental causes, the rule is that when these growths are heredi- 
tary they are either malignant or tuberculous. 

3. Clinical history. — Although these tumors may occur in infancy 
and childhood, and are not infrequent after the climacteric, they 
are most common during menstrual life, or between the ages of 30 
and 40. Their average duration is about three years, but they 
often begin their course so insidiously and develop so slowly that 
the date of their origin cannot be fixed with certainty. In 1880 I 
removed a compound ovarian cyst weighing fifty-six pounds which 
had been growing steadily for eleven years. In another of my 
cases a single cyst weighing forty-one pounds had appeared and 
developed within four months. Unless the cyst is single the more 
rapid the growth of the tumor the greater the chance of its being 
malignant. 

4 Symptoms. — The first symptom to attract the attention of 
the patient is the appearance of a swelling or of a "lump" in the 
right or the left inguinal region. Usually, but not always, she is 
very decided as to the early location of this growth. She will have 
observed that it is movable and painless, and that in changing the 



THE PATHOLOGY OF OVARIAN TUMORS. 909 

position of her body it disappears so that she can not always find 
it. This tumor may be tender at the month, and sometimes causes 
pain by pressing upon the sacral nerves. Any rough riding or 
jouncing, jumping, or straining at stool may excite nausea or cause 
her to vomit; but aside from these symptoms the swelling may 
exist for months, and possibly for years, without causing any seri- 
ous impairment of her health. 

In due time, however, the tumor increases in size, and grows 
toward the mesian line, the opposite side of the abdomen, and 
toward the umbilicus. Sometimes the sac fills very rapidly, and the 
strength fails in a corresponding ratio. The function of menstru- 
ation is variously affected. In a small share of cases the flow is 
suspended quite early, and the patient is sterile. Others have a 
temporary amenorrhcea, with a decrease of the flow and an increase 
of suffering. If the tumor is not traceable to a traumatic cause, 
there will almost always have been a history of dysmenorrhcea. 
These patients are often exempt from leucorrhoea, but perhaps one 
in ten or twelve of them may have had menorrhagia. 

The subjective symptoms in a growing ovarian cyst are such as 
we might expect from a distention of the 
The subjective signs, abdomen and from pressure upon the adjacent 
organs. Whether the bladder, the rectum or the 
uterus is most seriously disturbed in its functions will depend upon 
the direction which is taken by the developing tumor, and the 
degree of pressure upon the said organs. In the early stages, be- 
fore the cyst has mounted into the abdomen, these pelvic organs 
often suffer more than they do afterwards. Later on, when the 
uterus is retracted, as it almost always is, the sense of weight below 
the brim of the pelvis is relieved, and, if one of the sacs is not 
anchored within the retro-uterine space, the rectal symptoms dis- 
appear. If the patient has borne one or more children, the abdom- 
inal parieties will yield to the expanding tumor without any great 
feeling of distention or discomfort, until the freedom of the 
diaphragm is interfered with. But if these walls are put upon 
the stretch for the first time by the rapidly filling cyst, the patient 
will necessarily feel more pain than she otherwise would. In some 
of these latter cases, where there is an intolerance of the ovarian 
growth, symptoms analagous to those of pregnancy are present. 

One of the contingencies of the growing tumor is a tendency to 
repeated attacks of local peritonitis. This plastic inflammation 



910 THE DISEASES OF WOMEN 

seals it to the neighboring tissues and organs, and not only- 
increases the amount of suffering from time to 
Adhesions. time, but augments the danger from ovariotomy. 

Adhesions to the omentum, the intestines and 
the liver, are especially apt to involve the digestive function; while 
the anchorage of the tumor and its increasing growth may cause 
an inveterate pain in the lumbar region, obstinate constipation, 
albuminuria, uraemia, dropsy of the lower extremities and cardiac 
oppression. Dr. Fenwick* gives three symptoms as indicative of 
a serious cardiac involvment from this peculiar cause. These 
symptoms are, (1) a very feeble, rapid, and excitable pulse; (2) 
very dull and feeble heart's sounds, especially marked over the 
right apex;(3) and a very short systolic rise in the sphygmographic 
tracing. In some cases he also noted a great tendency to syncope. 
The ultimate tendency of the growth is to induce exhaustion of 
the physical forces, emaciation, and a pronounced cachexia. The 
features become shrunken, the face and expression are somewhat 
peculiar, and hence the fades ovariana which was once thought 
to be pathognomonic of this affection. The tumor grows at the 
expense of the other bodily tissues, and there is finally a remarka- 
ble disparity between the size and form of the extremities and of 
the abdomen. In case of hemorrhage, or of suppuration within 
one or more of the cysts, there will be signs of collapse, or of hec- 
tic with chills and rapid prostration. 

The objective or physical signs are more clear and satisfactory. 
Beginning with inspection, we observe that the 
The physical signs, tumor may or may not be symmetrical. The side 
upon which the swelling was first noted is usu- 
ally, but not always, the more prominent. If the distention is con- 
siderable, the form of the abdomen is peculiar in that its shape 
does not alter when the patient changes her position. It's profile 
is unvarying. The umbilicus may be deflected, but it is not 
retracted or depressed, nor does the region about it become flatten- 
ed on the top when the patient lies down. In old cases the abdom- 
inal walls are stretched and attenuated, and the muscular fibres 
spread apart, as in advanced pregnancy with twins, or dropsy of 
the amnion, and the veins stand out prominently at the sides of 
the tumor. Exceptionally, when there is an unusual deposit of fat 

*On intra-abdominal tumors as a cause of Cardiac Degeneration. British Gynecological 
Journal, vol II, page 72. 



THE PATHOLOGY OF OVARIAN TUMORS. 911 

"beneath the muscles, the striae are not to be seen npon the integu- 
ment. In oligocysts, where there are but two or three large sacs, 
the lines which separate them may sometimes be easily recog- 
nized; and the sulci between the solid and the cystic portions of 
certain ovarian tumors are quite significant. I have learned to 
place more confidence in the physiognomy of the abdomen as a 
sign of these tumors than I have in the face itself, although one 
may indeed help us where the other fails. 

By mensuration, the size and certain relations are easily made 
out. The measurements usually taken are from the xiphoid carti- 
lage (which may be deformed) to the umbilicus, and thence to the 
upper margin of the symphysis pubis. This is the perpendicular 
diameter, and recalls Professor Simpson's rule that, if its length 
below the umbilicus exceeds that which is above it, providing the 
case is well developed, the tumor is uterine, and not ovarian. Next 
comes the girth around the body and over the most prominent 
part of the tumor; and after that the oblique measurements, which 
extend from the umbilicus to the anterior superior spinous pro- 
cesses of the right and left ilia. These measurements should be 
recorded on the spot. 

Palpation, or the external touch, gives an idea of the abdominal 
heat and tenderness, the mobility of the investing integument and 
of the tumor, the simple or composite character of the tumor, its 
softness or hardness, the course of its outline, its compressibility, 
and of the sulci between its component cysts. If the abdominal 
parieties can be grasped by the handful, the growth is not a large 
one; if the latter can be carried upwards beneath the umbilicus, 
the tumor is not uterine. 

Bimanual examination shows that, if the cyst can be moved 
about without changing the position of the uterine cervix, it is 
probably ovarian. It is not very unusual for the neck of the womb 
to be so drawn up by the developing cyst as to be beyond the reach 
of the finger. I have now, 1887, made six ovariotomies where the 
uterus was so retracted and changed in its contour that it could 
not be felt or found before the operation. Three of the cases were 
benign, and made a good recovery, the other three were cancerous 
and fatal. 

Percussion is invaluable because it serves to mark the outline 
and certain physical characters that are peculiar to the cyst and 
its contents. The tendency of these tumors to come forward, to 



912 THE DISEASES OF WOMEN. 

lie against the abdominal parietes, and to push the intestines with 
their contained gases upward and backward, out of the way, makes 
it possible by this means to map out these tumors and to decide 
whether their contents are fluid, solid or mixed. By it we can detect 
the water-line, and the fluctuating wave-line; can often tell whether 
the serum is contained in a single or in numerous compartments; 
can judge of its tenuity or of its thickness, and whether the case is 
complicated with ascites or some other incidental affection. (See 
Figs. 17, 18 and 19.) 

Abdominal auscultation being more applicable and serviceable 
in the detection of solid tumors has little more than a negative 
merit in cases of ovarian dropsy.* 

II. DERMOID CYSTS OF THE OVARY. 

1. Morbid Anatomy. — These cysts are the most curious of all 
morbid productions. Their chief peculiarity is found in their con- 
tents, which consist of a comparatively small quantity of fluid mix- 
ed with such growths and foreign substances as are never found 
in other ovarian tumors. These foreign bodies consist of hair, 
teeth (of the bicuspid variety when they are numerous, and of the 
canine when not numerous), of bits of alveolar processes with 
teeth in them, of rudimentary teeth which are set in cartilage, of 
flat bony plates and spiculse, of finger nails, of skin with its com- 
ponent parts, and vessels filled with morbid deposits or sebaceous 
secretions, of nerve tissue and striped muscular fibres, of scales of 
cholestrin, and fat in considerable quantity, which may be as firm 
as lard or tallow, or oily and beaten up like a pomade. Sometimes 
the cyst is a suppurating one and may furnish a large quantity of 
pus, but if the quantity of pus is small it may have been replaced 
by a putty-like material resembling Chinese white. 

It is a singular fact that these dermoid tumors of the ovary may 
exist in infancy, and even in the foetus in utero. They often occur 
in young women, and are seldom seen in those who have passed 
forty. Doran cites a case in a woman aged 63, and Atlee one that 
was without a pedicle in an unmarried lady of 79, and who had 
carried the tumor for forty-seven years. They are almost always 
congenital, but remain latent through childhood until after puber- 
ity. Sometimes the occurrence of pregnancy stimulates their 
growth, after which they may occasion pressure upon the neigh- 

*For the Differential Diagnosis of Ovarian Cysts see Lecture LVII. 



THE PATHOLOGY OF OVARIAN TUMORS. 913 

boring parts. It is only, however, when the tumor is solid, or 
when its walls are thick and firm, that it causes any considerable 
pain or discomfort. 

A single compartment of a compound dermal cyst of the ovary 
may contain such a medley of morbid products as I have named, 
while the remaining sacs are filled with the ordinary ovarian fluid. 
We occasionally find some of these foreign matters in multilocu- 
lar tumors of the ovary. 

2. Etiology. — I have elsewhere treated of this subject in the fol- 
lowing manner:* 

These peculiar tumors "were in times past looked upon as inex- 
plicable marvels, and not only had their entry into museums as 
treasures, but were described with scrupulous verbosity. There is, 
however, nothing more extraordinary in them than in the appear- 
ance of bone in the gluteus, or imperfect brain-like matter in the 
substance of the mammary gland, or fibrous nodules in the lobes 
of the cerebrum. Their chief surgical interest is in the obscurity 
they throw over diagnosis, and in the complications they occa- 
sion. {Spencer Wells.) 

Various theories have been proposed in explanation of the origin 
of these cutaneous tumors of the ovary. The most popular was 
that of fcetal inclusion, a foetus within a foetus, which referred 
them to the blighting of a twin-f cetus, and its inclosure within the 
ovary of its mate, while the latter underwent the proper develop- 
ment and came to maturity. Another idea was that the contained 
morbid products could only have resulted from the impregnation 
of the patient; or in other words, that a dermoid cyst of the ovary 
was of necessity the result of an extra-uterine pregnancy. A third 
was that of parthenogenesis, or the development of an ovum with- 
out impregnation; and a fourth referred to incomplete embryonic 
development of the epithelial cells of the ovary itself. But such 
speculations are fanciful and not profitable. The conclusion of a 
recent writer on this subject commends itself: "I think the best 
solution of the question is that of the invagination of the blasto- 
dermic membrane, the external layer of which develops the organs 
of animal life. If, therefore, there should be an inclosure of any 
part of this membrane within any organ of the body, these epider- 
mal formations would readily be produced." (Helmuth.) "The 
dermoid ovarian cyst question appears to me to be closely and 

*Arndt 1 s System of Medicine, vol. II, page 365. 



914 THE DISEASES OF WOMEN. 

inseparably linked with some of the most profound mysteries of 
organic life." (Doran.) 

3. Diagnosis, — The fact that these dermal tumors may be car- 
ried for a long time without any very decided impairment of the 
general health, and without attaining any great size, as well as 
their firmness and solidity when their wall is thick and when they 
are filled with solid or semi-solid contents, has frequently caused 
them to be mistaken for uterine fibroids. Unless there is inflam- 
mation in some of their structures, or pressure by them upon the 
neighboring organs, both these kinds of tumors are insensible and 
painless, of slow growth and innocuous, and both may undergo 
cystic or sarcomatous degeneration. But there are, however, a 
few points which may serve to differentiate them. "With the 
fibroid growth there is a history of a coincident menorrhagia; the 
tumor has very little tendency to anchor itself through inflamma- 
tion of its capsule, or of its investing peritoneum; and it is very 
rare indeed for it to undergo the process of suppuration. On the 
contrary, the dermal cyst is seldom accompanied by a profuse 
menstruation; it almost always becomes immobile through adhe- 
sive inflammation , and it is very prone to suppurate. Most uterine 
fibroids which have attained a considerable size grow decidedly 
larger with the return of the monthly period, and, afterwards 
diminish with the decline of the flow, which is not true of these 
cutaneous cysts. Although it may be present, ascites is not a com- 
mon accompaniment of uterine fibroids, while it is almost never 
absent in a dermoid cyst of the ovary which is large enough to 
claim our professional attention. When the dermoid cyst is located 
either in the posterior or anterior cul-de-sac, or anywhere at the 
roof of the vagina where it is accessible to the touch, there is 
almost always a perceptible fluctuation. This is not true of 
uterine fibroids. 

When these clinical points are not sufficient to enable us to de- 
cide between them, it may be expedient to resort to tapping by the 
aspirator-needle, the careful introduction of which will help to 
determine whether it has passed into a sac or into a solid growth; 
while, if any fluid is withdrawn, it may serve to settle the charac- 
ter of its contents. If the fluid contains hair or epidermal scales, 
or if it resembles candle-grease or melted-butter, after you have 
forced it from the barrel of the instrument into a glass, and espec- 
ially if it solidifies so that you can turn the glass upside-down 



THE PATHOLOGY OF OVARIAN TUMORS. 915 

without spilling it, and dissolves again by placing the glass in warm 
water, the diagnosis is clear. (Laroyenne.) 

The reduction in the size of the tumor by this species of tap- 
ping, and the facility with which it refills, are characteristic and 
confirmatory. It is important to remember that if the needle 
strikes upon a bony structure, or even if bits of bone, teeth, and 
the like are discharged through fistulous openings in the rectum, 
the vagina, the bladder, or the abdominal parieties, the case is not 
necessarily one of extra-uterine pregnancy. Mistakes of this kind 
have often been made, and have sometimes given rise to social un- 
happiness when it should have been prevented. , 

Since a dermal growth may be composite, and may have one or 
more cysts, which contain a proper ovarian fluid, and since one 
ovary may be the seat of such a growth while the opposite one has 
undergone the ordinary cystic degeneration, the mere removal of 
a quantity of ovarian fluid by tapping does not preclude the pos- 
sibility of a dermoid cyst. In these cases the diagnosis must be 
settled by the exploratory incision, or bv ovariotomy. 

III. FIBROID TUMORS OF THE OVARY. 

1. Clinical history. — There are three points of interest in the 
study of fibroid tumors of the ovary: (1) their variety, (2) the dif- 
ficulty of their diagnosis by any means short of 

Their comparative the exploratory incision, and (3) their proper 
surgical treatment. Of their variety we may 
justly say that they have been found more often by the patholo- 
gist than by the gynecologist, in the dead than in the living. Un- 
til quite recently most operators have decided with Atlee that 
"when a tumor possessing the usual characteristics of a fibroid is 
found in the abdominal cavity, we may, as a general rule, decide 
it to be uterine." The aversion to cutting down upon a fibroid, 
and the tradition that while cystic growths were removable with 
comparative safety, the excision of fibroids, whether of th e uterus 
or of the ovary, was unaccountably and almost universally follow- 
ed by a fatal result, has caused many an ovarian fibroid to be over- 
looked. Now that laparotomy has put a window in the abdomen 
we shall probably see more of these peculiar growths, and remove 
them too, with safety to our patients. 

Another dictum which has hindered and yet hinders the recog- 
nition of ovarian fibromata in certain cases is the statement that 



916 



THE DISEASES OF WOMEN. 



they are always of a small size, and that a large abdominal fibroid 
must necessarily be of uterine origin. Even Tait endorses the 
statement of Peaslee, who says that: "Fibroids of the ovary are 
very rare, and do not often exceed the size of a goose-egg." But 
Greig Smith* reports having "successfully removed a solid ovar- 
ian tumor as large as a child's head, in which repeated examina- 
tions by competent histologists failed to show any other histologi- 
cal element than pure fibrous tissue." And Dr. Mann has been 
equally successful in extirpating an undoubted fibroma of the 
ovary that weighed seven pounds.f Doran gives a very interesting 
cut of a myoma of the ovary, which had been growing for eight 
years, which was successfully removed by Sir Spencer Wells from 
a single woman aged sixty-eight, and weighed 15 lbs. 2 oz. (See 
Fig. 173.) 




Fig. 173. Myoma of the ovary. (Doran.) 

2. Morbid anatomy. — The first five of the conclusions of Dr. 
Coe in a remarkable paper on "Fibromata and Cysto-fibromata of 
the Ovary" J include all that you will need to know upon this part 
of my subject. They are as follows: 

1. Fibrous tumors may and do arise from the ovary, independ- 
ent of the uterus or the other adnexa. 

2. In structure these tumors are true fibromata, yet peculiarly 
rich in long spindle-cells, which closely resemble those of the nor- 
mal stroma; hence, 

3. These fibromata originate, not by a local change, but as the 

*Abdominal Surgery, by J. Greig Smith, etc., etc., 1887, page 130. 
fThe American Journal of Obstetrics, etc., May, 1887, page 451. 
tlbid, Vol. XV., 1882, page 876. 



THE PATHOLOGY OF OVARIAN TUMORS. 917 

xesult of a general hyperplasia of the ovarian stroma. Moreover, 
there is nothing to show that this process is of an irritative, or 
inflammatory character. 

4. The resemblance between microscopic sections of ovarian 
and uterine fibroids is so close that the differential diagnosis is 
very difficult, if not impossible. 

5. Cysto-fibromata of the ovary, like those of the uterus, are 
of secondary formation, and result from changes in previously 
solid tumors. 

3. Diagnosis. — If the patient is intelligent and is quite positive 
that the hard swelling or "lump" was first detected in the ingui- 
nal region, or that it developed from that quarter, or that it has 
always inclined to either side of the pelvis, the fact is suggestive 
of its ovarian attachment. If it is, and has always been, very 
movable, rolling about whenever she changed her position from 
side to side, the symptom is confirmatory. If the growth is pain- 
less, or nearly so, and accompanied by dragging sensations, and 
downward pressure when she is standing; but more especially if 
the tumor has a rounded outline, a smooth surface, a hard and 
firm texture ; if it can be moved independently of the uterus, and 
if it is accompanied by an ascitic accumulation, the subjective 
symptoms may be said to be pretty well marked. They are not 
decisive, however, for the same symptoms might be present in an 
extra-uterine fibroid that was attached by a slender pedicle to the 
front or to the side of the uterus. There is this difference between 
them, that while the ovarian fibroid is almost always accompanied 
by ascites, the uterine myoma is not; and that, while the former 
does not give rise to menorrhagia, the latter almost invariably 
does. The signs revealed on auscultation are the same in both 
cases. It rarely happens that both ovaries are the seat of fibrous 
growths. More often one ovary is cystic and the other solid. 
It is well to remember, however, that the most expert and exper- 
ienced gynecologist can not always make an abso- 
La ?o8^^source iag " ^ e diagnosis of an ovarian fibroma without are- 
sort to the knife. The exploratory incision will 
not only enable us to complete the diagnosis, but to determine 
whether it is expedient to remove the tumor. ( See Lecture LVIII. ) 



LECTUKE LVI. 

THE PATHOLOGY OF OVARIAN TUMORS— Continued. 

Malignant tumors of the ovary.— 1. Cysto-sabooma. Case. Physical signs. Rupture of the 
sac. The rule for tapping. Aspiration. Differential diagnosis. Ovariotomy. 2. Cysto- 
OABCINOMA. Clinical history; Symptoms; Diagnosis. 3. Soibehtjs of the ovary; His- 
tory and symptoms. 4. Colloid ob Myxoma; not always cancerous. Tait on malignancy 
of. 5. Papilloma, epithelioma and oaulifloweb degeneration of the ovaby. Case. 
6. Enoephaloid of the ovaby. Case. 

IV. MALIGNANT TUMORS OP THE OVARY. 

With very few exceptions malignant tumors of the ovary are 
composite, or partly solid and partly cystic. Usually, but not 
always, the solid portion is the first to be developed. The cystic 
portion is certain to become the more bulky of the two. The clin- 
ical varieties of these malignant ovarian tumors are (1) cysto- 
sarcoma, (2) cysto-carcinoma, (3) scirrhus, (4) colloid, or myxoma, 
(5) papilloma, epithelioma and cauliflower degeneration, and (6) 
encephaloid of the ovary. 

1. CYSTO-SARCOMATOUS, OR FIBRO-CYSTIC TUMORS OF THE OVARY. 

The several important points in the history and diagnosis of this 
kind of ovarian tumors are the comparative slowness of their 
growth until the cyst has formed and is partly rilled; the irregular 
shape of its solid portion and its recurrent tendency after it has 
been removed; its disposition to mass the womb with the tumor 
so that it cannot be identified, and the refilling of the sarcoma-cyst 
or cysts, which are sometimes very large, after they have been 
tapped. 

The following case was sent to the hospital by Dr. E. D. Kan- 
ouse & Son, of Appleton, Wis., and the remarks appended consti- 
tuted my clinical lecture upon it, delivered in the hospital Febru- 
ary 19, 1885: 

Case. — Mrs. , married, aged forty-six, has conceived only 

once, which occurred twenty years ago. The child was still-born^ 
She enjoyed comparatively good health until fourteen years ago, 
when an enlargement was observed in the left ovarian region. 
This enlargement grew slowly for a period of five years, giving 
rise to no special inconvenience. The abdomen had attained a cir- 
cumference of between thirty-six and thirty-nine inches, when she 

918 



THE PATHOLOGY OF OVAKIAN TUMORS. 919 

received a fall, soon after which the abdominal enlargement 
diminished. From this sudden disappearance of the tumor it was 
supposed that it must have been ruptured by the fall. No per- 
ceptible discharge occurred, neither did the patient suffer any spec- 
ial shock or inconvenience, saving a slight weakness for a few days. 

Following this accident, an enlargement appeared in the right 
ovarian region, developing quite rapidly for eighteen months, when 
it also was ruptured spontaneously. At this time a very small 
quantity of a thin, inoffensive fluid escaped per vaginam. 

This sac apparently refilled, and in one year more ruptured 
again; the abdomen decreasing in measurement within about 
twenty-four hours, from a circumference of forty-one to twenty- 
two inches. At this time there was a clear, inoffensive, syrupy 
exudation from the skin, necessitating a constant sponging of the 
patient for three days and nights, and then it gradually disappear- 
ed. No serious illness followed, and she was about as usual, after 
the lapse of ten or twelve days. 

But this did not end her trouble, for soon it was noticed that the 
-tumor was again developing. The progress of this growth has 
been very much slower than that of the preceding two, having cov- 
ered a space of six years in attaining its present size. 

During the last five years the menstrual periods have been very 
irregular. The flow is copious, dark-colored and clotted, lasting as 
a rule for ten days, and being preceded by and accompanied with 
intra-pelvic pain, notalgia and cephalalgia; and during the past two 
years the discharge has had an extremely offensive odor. She occa- 
sionally has slight pelvic pains during the inter-menstrual period. 
The urine is normal; the bowels are constipated; the oedema of the 
lower limbs is quite marked. 

Her mother died at the age of fifty-six of cancer of the womb, and 
an aunt, her mother's sister, died of some morbid growth of the 
stomach; but with these exceptions the health of the family seems 
to have been good. 

I will not repeat what has already been said and shown you, con- 
cerning the different methods of physical diag- 
Physicai signs. nosis in abdominal tumors, but proceed at once 
to discuss the peculiar clinical features of this 
case. Observe that percussion gives a singular outline to this con- 
tained growth. I will mark it with a pen, so that you can all see 
it. While its margin on the left side, and transversely below the 
thorax, is rounded, it gives us a triangular patch of resonance on 
the right side, the apex of which points across the abdomen, and 
nearly reaches the mesian line, about half-way between the umbil- 
icus and the pubes. ( See Figs. 174-5 ) Such irregularities of out- 
line, and there is a variety of them, almost always signify that the 



920 THE DISEASES OF WOMEN. 

tumor is composite. That this tumor is partly cystic is shown in 
the history of its having been ruptured, as well as by a percepti- 
ble fluctuation, especially at its left and superior portion. 

Although you are aware that the womb is usually drawn upward 
and forward in ovarian tumors, it may surprise some of you to 
learn that it cannot be felt or found, per vaginum, in this case. 
When the uterus is lost in this way it may be a good or a bad sign. 
It is always an obstacle to diagnosis. It may have adhered to the 
wall of an ovarian cyst, and been retracted as the sac has devel- 
oped, and no harm come of it; but if it is included and imbedded 
in a solid growth which lies above the superior strait, the case is 
very different. We shall see. 

But what of the repeated rupture and the disappearance as well 
as the refilling of this tumor ? Briefly, there are three kinds of rup- 
ture which may either temporarily or perma- 

Bupture of the sac. nently dispose of the fluid contents of an ovarian 
cystoma : ( 1 ) there may be a leak through which 
the fluid is discharged very gradually ; or (2) there may be a break- 
ing down of the partition walls of a' multilocular cyst, so that its 
compartments may communicate, and the shape and size of the 
tumor be changed; or (3) it is possible to have a large-sized rent 
through which the fluid may be poured into the peritoneal cavity. 
The cause for either of these kinds of rupture is atrophy or disten- 
tion, or both, and not ulceration of the cyst-wall as is generally 
supposed. 

A considerable share of these cases of spontaneous rupture re- 
cover, and the cyst does not refill; but others are fatal. You should 
remember, that when the first rupture is not accompanied by 
shock, or followed by illness, and especially if there is no reaccum- 
ulation of its fluid contents, the tumor is a cyst of the broad liga- 
ment, or something else, and not a proper ovarian cyst. 

Not only does the true ovarian cyst fail to disappear by a spon- 
taneous evacuation, or even by a single tapping, but it is peculiar 
in another respect, which is that every time it refills its contained 
fluid becomes more depraved in quality, so that, although such a 
cyst might possibly break for the first time and pour its innoccu- 
ous contents into the peritoneal cavity without harm, this thing 
could not be repeated very often with impunity. We do not know, 
and nobody knows what kind of fluid escaped from this sac when 
it collapsed the first, or even the second time that it yielded; but 



THE PATHOLOGY OF OVARIAN TUMORS. 921 

if this last accummulation is ovarian, it is next to impossible that 
it should not be vitiated. 

The irritating and poisonous qualities of the ovarian fluid, espec- 
ially if it conies from an old sac, are known to you. When such a 
tumor has been tapped a very few times it becomes septic in a high 
degree, and this is why repeated tapping increases the risks of a 
subsequent ovariotomy. Providing death does not follow from 
shock, or peritonitis, or hemorrhage, or from all these, an early or 
a repeated rupture of the cyst-wall will have the same effect. 

From this point of view, therefore, you perceive that, since this 
growth has so nearly attained its maximum size, or the point of 
distention at which it burst on two former occasions, our patient 
is really in a perilous condition. On the theory that the fluid 
which fluctuates beneath my hand is very poisonous, it should not 
be permitted to escape into the abdomen; for the greedy lymphat- 
ics, of which the peritoneum is almost entirely composed, would 
absorb it and develop a speedy and fatal infection. 

There is another reason why I have brought this woman before 
you, which is to illustrate the impossibility of making a satisfac- 
tory diagnosis in some of these cases without a 
The rule for tapping, resort to tapping, or to the exploratory incision. 
The former of these final methods of diagnosis 
has been very much abused — abused by those who have practised 
it without the proper discrimination, and whose carelessness has 
greatly increased the mortality from ovariotomy ; and more recently 
abused by a few leading specialists who go to the other extreme, 
and who insist that it should no longer be practised under any 
circumstances whatever. 

Now there are several good reasons why, in my judgment, tap- 
ping is advisable in this case, which is certainly an exceptional 
one. They are (1) to avoid the imminent risk of another rupture, 
for the circumference of the abdomen is thirty-nine and a-half, 
instead of forty-one inches; (2) to remove the fluid in order that 
it may be examined; (3) to get it out of the way of a further phys- 
ical exploration; (4) to decide whether the tumor is wholly cystic 
or if it is composite, and if possible, to find the whereabouts of the 
womb; and (5) to enable us to decide intelligently whether, and 
if so, what further operative treatment is expedient and necessary. 

Tapping is usually a very simple operation, but in such a case 
^as this we must proceed cautiously. With the form and outline 



922 THE DISEASES OF WOMEN. 

of this tumor, and this acute angle of resonance coming so near to 
the mesian line, we might puncture a coil of intestine ; or, if the cyst- 
wall happens to be very weak and attenuated, it may leak around 
the needle, or the canula, or possibly fail to close the orifice when 
the instrument is withdrawn. It will be safer, therefore, to use 
the aspirator than to take the ordinary trocar, although it may 
happen that the fluid is too thick to flow through its slender needle. 

The patient is sensible and intelligent, and is quite willing for 
11s to do whatever is best. We will, therefore, try the aspiration 
as a means of relief to her and of information 
Aspiration. and help for ourselves, but not as a curative 

measure. Having selected a point on the linea 
alba one-third the distance below the umbilicus, the skin is touched 
with a strong solution of carbolic acid to anaesthetize it, and as an 
antiseptic precaution. In passing the needle I feel that it enters 
a cavity and is fairly within the compartment containing a fluid. 
My assistant exhausts the air-chamber of the instrument, and you 
will see in a moment what kind of fluid fills the sac, and whether 
my prediction that it is bad enough is verified. I turn this little 
stop-cock, it flows freely, and you can all see that it is of a dark > 
chocolate color. It is morally certain that, if this fluid had escaped 
into the peritoneal cavity, the risk of malignant infection 
would have been very great. I do not see how she could have sur- 
vived it. 

The aspirator empties these large collections very slowly, but it is 
a safer instrument than the old trocar, not only because there is no 
possible admission of atmospheric air into the sac, or the tissues, 
but because the discharge is so slow that it prevents shock, and 
permits the abdominal organs gradually to accommodate them- 
selves to their change of position. 

We have now emptied the tumor of its fluid contents, eleven and 
a-half pints in all of this chocolate-looking mixture, and I am 
going to withdraw the needle. This fluid is all of one kind, which 
is evidence that we have to do with a single sac, and we may learn 
something by the caref ul removal of the needle. Observe that I 
hold it in a peculiar position so that I may know if the sac has col- 
lapsed, and may be able to indicate its place of attachment when 
it drops from the point of the needle. She will now be carried to 
one of my private rooms in the hospital, where she will have every 
care to prevent any ill-effects from this operation; and if every- 



THE PATHOLOGY OF OVARIAN TUMORS. 



923 



thing goes on well, I will complete the examination and the diag- 
nosis in this amphitheatre in a few days, or as soon as it can be 
done with safety. 

Monday, February 23. — Our excellent house physician, Dr. 
Eddy, has had such a care of our patient that she has escaped all 
harm, and I have had her brought before you again. You will 
observe the difference in the contour of the abdomen. The 
enlargement at its upper part has disappeared, the belly is hollow- 
ed out, and the line of dulless is horizontal, passing transversely 
about one-third of the distance below the umbilicus. Above this 
line the abdomen is resonant, below it the sound is flat; above it 
the distended sac has collapsed and disappeared, below it the 
\ 





Fig. 174. Ovarian cysto-sarcofna before and after tapping. 

tumor that remains is solid and immovable. The uterus can not 
be identified, either internally or externally. The mass is irregu- 
lar, not rounded like a benign fibroid, and not sensitive as it was 
at the close of the tapping. 

The patient has stated one fact not contained in the record of 
her case, which is that, directly after the rupture of the sac, six 
years ago, the abdomen "was as flat as that of a young girl," and 
that there was no sign of any remaining tumor in it. If this is 
true, and I see no reason to doubt it; if the uterus was retracted 
then as it is now; and if the menorrhagia began soon after, it is 
fair to infer that the development of the solid portion of this 



924 THE DISEASES OF WOMEN. 

tumor, followed the development of its cystic portion. This order 
of consequence is the reverse of what takes place in fibro-cystic 
tumors of the uterus. But in cysto-sarcoma, and also in cysto- 
carcinoma of the ovary, the solid part may be first and the cystic 
secondary, or vice versa. 

But, what is this solid growth? Is it benign, or malignant, car- 
cinomatous or not? It is manifestly ovarian although the uterus 
is certainly involved and included in the mass. I believe it to be a 
cysto-sarcoma of the ovaries, although in some respects it resem- 
bles cysto-carcinoma of the same organs. Here is a parallel 
between the symptoms of each: 

Ovarian cysto-sarcoma. Ovarian cysto-carcinoma. 

The rounded outline of the The surface of the tumor is 

tumor. irregular and nodulated. 

The tumor is not especially It is almost always tender and 

sensitive. sensitive. 

There is almost always a his- Menorrhagia is exceptional, 

tory of menorrhagia. Ascites and anasarca are the 

Almost never a pronounced rule and not the exception, 

ascites, or any dropsy of the feet. The pulse is like that of phth- 

The pulse is not habitually isis. 
rapid. In a confirmed case the each- 
There is no peculiar cachexia, exia is always present. 

The solid portion of the The more malignant the solid 

tumor develops slowly. growth the more rapid its devel- 
opment. 

Is this a suitable case for ovariotomy? I think not. The tumor, 
if not really malignant, is of the recurrent variety; the pelvic 
adhesions are very formidable, and the uterus is lost in the mass, 
and must come out with it. The case is very like the one in which 
you saw me remove both ovaries and a portion of the womb in 
October last, and which terminated fatally. I have now operated 
upon six cases in which the uterus could not be identified before 
the incision was made. Of these three have indeed recovered, but 
in each of the three that organ was adhered to the ovarian cyst, 
and had been retracted beyond reach. In the other three it was 
lost in a solid growth of this kind. At the request of my friend, 
Dr. John Moore, I saw a case like this when in Liverpool, two 
years ago. Within a month afterward it was removed by the cel- 
ebrated ovariotomist, Dr. Keith, of Edinburgh, but despite his 
acknowledged skill, the operation resulted fatally. So that, with 



THE PATHOLOGY OF OVARIAN TUMORS. 925 

the history that has been given you, and the points that have been 
made concerning this patient's case, I think it most prudent and 
advisable to send her home without an operation, for, in all human 
probability she would not survive the removal of this mass.* 

2. CYSTO-CAROINOMA OF THE OVARY. 

Although the ovary is more liable to undergo cystic degenera- 
tion than any other organ in the body it is com- 
ciinicai history, paratively exempt from cancer, especially in its 
primary form. Any and all of its textures are 
liable to this kind of degeneration and of infiltration. For this 
reason, if the trouble begins in the areolar or the fibrous tissues of 
the ovary it may develop slowly and for a long time without 
involving its follicular portion. True cancer-cysts of this organ 
when they are of secondary growth may be numerous, but they are 
not usually so large, nor is their wall so thick as in fibro-cystic 
tumors of the ovary. 

The symptoms vary with the size, location and firmness of the 

tumor, conditions that involve pressure within the pelvis and which 

give rise to local pains, neuralgia, sciatica, rectal 

Symptoms. and vesical obstruction, recurrent peritonitis and 

cellulitis with or without suppuration. This 

form of ovarian tumor is more painful than any other, and as in 

other varieties of cancer it is sooner or later accompanied by an 

impairment of the appetite and digestion, anaemia and emaciation. 

Anasarca and ascites are the rule and not the exception in old 

cases. 

As already stated, this form of ovarian cancer is usually second- 
ary upon the same lesion located elsewhere. By the time that it 
can be recognized the constitutional cachexia will have been 
developed. The coincident lesions, more especially the peritoni- 
tis, will have resulted in the anchorage of the tumor which in- 
creases the suffering and greatly complicates the possibility of its 
removal. 

"Any solid tumor of the ovary will awaken the attention and 

cause one to suspect the existence of a cancerous 

Diagnosis. growth. This suspicion will be the stronger if 

both ovaries have been attacked, if the pain is 

* Under date of September 2, 1887, Dr. K. writes that this patient is in better health than for 
the past six years. In the interval the tumor has been twice tapped, each time yielding about 
six quarts of a fluid resembling New Orleans molasses. 



926 THE DISEASES OF WOMEN. 

intense, if the development of the tumor has been rapid, if there 
is a marked degree of ascites, and finally if the emaciation and the 
cachexia, and the general and local oedema are out of proportion 
with the size of the tumor. The age of the patient is also a sign 
that is worthy of note, for ovarian cancer is generally found in 
younger persons than is cancer of other organs." (Mustache*) 

The differential diagnosis between the cysto-carcinoma and 
cysto-sarcoma have just been given you. (See page 924) 

3. SCIRRHUS OF THE OVARY. 

This form of ovarian cancer is extremely rare; is seldom larger 
than an orange, is almost always of secondary 
History and symptoms, formation, and connected especially with scirr- 
hus of the uterus and of the broad ligaments; it 
affects both ovaries at the same time; is most frequent in unmar- 
ried women; and is peculiar through its exemption from adhesive 
inflammation, its mobility, painlessness, and its failure to undergo 
any form of cystic or calcareous degeneration. The surface of 
this kind of tumor is comparatively, although not absolutely, 
smooth, and, therefore, it is not usually accompanied by ascites. 
Indeed this circumstance causes it to be confounded with fibroma, 
or myo-fibromata of the ovary. The chief distinction between 
these two varieties of ovarian tumor, both of which are rare, is that 
the development of the cancerous cachexia is incident to one of 
them and not to the other. 

The expediency of removing a scirrhous growth of the ovary by 
laparotomy, will depend upon the involvment of the uterus and 
the broad ligaments, and upon the constitutional condition of the 
patient, the family history, the duration of the disease, the emaci- 
ation and the digestive impairment; and since all of these condi- 
tions cannot be otherwise determined, it will sometimes be proper 
to settle the question by a resort to the exploratory incision. 

4. COLLOID OR MYXOMATA OF THE OVARY. 

It is unfortunate that the term "colloid," which means a gelatinous 
substance, should have been applied to a variety 
Not always cancerous, of ovarian growths ; and still more unfortunate 
that authorities are not agreed as to the malig- 
nancy, or non-malignancy of these tumors. Formerly every ova- 
rian tumor that yielded this species of jelly-like discharge was .be- 
lieved to be cancerous, and the rupture of cysts with colloid con- 



THE PATHOLOGY OF OVARIAN TUMORS. 927 

'tents was thought to be fatal through the absorption of cancerous 
material. Now we know that, unless the intra-cystic contents con- 
sist of some form of papillomatous growth, the mere fluid contents 
of the sac are not sufficient proof of its cancerous nature. I have 
repeatedly removed multilocular tumors of the ovary in which the 
cysts contained a large amount of this colloid material; but so far 
as I have been able to trace the subsequent history of these cases, 
in only one of them has there been any recurrence of the disease. 
In that case both ovaries were involved, much of the colloid materi- 
al was hardened into form like moulded jelly; the two tumors 
weighed sixty pounds; the patient made a good recovery and lived 
for eighteen months when she fell a victim to a rapidly developing 
cancer of the peritoneum with ascites. 

A prominent author says "the term colloid, as applied to tumors 

of the ovary, must be held to refer only to the 
Tait on coUoidtnmors consistency of the fluid contained in them, and 

in no way as a point for classification. I have 
never met with a description which has persuaded me that 
the so-called colloid cancer, as seen in the breast, intestines and 
peritoneum, has ever been met with in the ovary. What we see of 
it is the myxoma already described, and which is always quite 
localized in the tumor, a mere incident, as it were, never forming 
the mass of the growth. In other organs it is practically a malig- 
nant disease, but whether it is so in the ovary I do not know. It 
is, as I have said, the reversion of the stroma of the ovary to its 
young form, and may therefore be suspected." (Lawson Tait) 

5. PAPILLOMA, EPITHELIOMA AND CAULIFLOWER DEGENERATION 
OF THE OVARY. 

Papilloma, or wart -like growths upon the ovary are either extra- 
or intra-cystic. They may be sparse or exuberant, are very fria- 
ble, and their presence is usually accompanied by a large amount 
of free fluid in the form of ascites, or large accumulation within 
the cyst- wall. When they are attached to the outer surface of the 
sac, they not only give rise to abdominal dropsy, but similar vege- 
tations are apt to be found upon the surface of the peritoneum. 
Sometimes these peritoneal sprouts are developed in consequence 
of the rupture of the cysts and the resulting extravasation of their 
contained fiuid. It has been claimed that frequent tapping of a 
benign cyst may possibly result in the formation of these papillo- 



928 THE DISEASES OF WOMEN. 

matous growths, especially if any of the cystic contents shall have 
passed into the peritoneal cavity. 

Ovarian epithelioma usually begins within the cyst, and may be 
limited to its cavity; but, if the cyst is ruptured the lesion may ex- 
tend to the solid portion of the tumor, and to the neighboring sur- 
faces. The greater its extension the larger the ascitic accumula- 
tion, and the more pronounced the cancerous cachexia. 

Cauliflower degeneration of the ovaries, of which Plate II, taken 
from a specimen that was removed in my clinic, gives a faithful 
illustration, is undoubtedly the rarest of all the forms of ovarian 
tumors. Its symptoms are not distinctive from those of other 
varieties of ovarian cancer. Its morbid anatomy is peculiar in 
that its development results in the destruction and disappearance 
of the cyst-wall, while in old cases there is general anasarca, ascites, 
emaciation, the cancerous hue of the skin, and the usual evidences 
of a cancerous cachexia. Secondary cardiac and renal lesions are 
the rule and not the exception. 

The following case was first shown in my hospital clinic April 
10, 1882: 

Case. — Mrs. , aged 43, the mother of two children, has 

always enjoyed good health and been in good flesh until about a 
year ago, when she began to grow thin, after which she discovered 
that the abdomen was very much larger than it should be. This 
enlargement began at the lower part of the abdomen and extended 
upward. A little while afterward she had a fall, which jarred her 
badly. Since July, 1881, now nine months, she has been tapped 
three times. The first time, the distention was enormous, and fifty 
pounds of fluid were withdrawn, after which an umbilical hernia 
was developed. In October, 1881, the operation of ovariotomy 
was attempted and relinquished by some physicians in the coun- 
try, and she was tapped again, but does not know how many 
pounds of fluid were taken. In January, 1882, she was tapped a 
third time, and thirty-one pounds of serum were removed. 

After the third tapping, the hernia once became strangulated, 
but was relieved by manipulation under chloroform. It is now very 
sore and she is obliged to wear a truss. There is a cicatrix four 
inches long, resulting from the incision made in October last, and 
several scars from the tappings and the sutures. The enlargement 
of the abdomen, which is much less than before the first tapping, 
is chiefly below the umbilicus, except upon the right side, where 
the dullness on percussion extends to the hepatic region. In the 
left lumbar region there is resonance on' percussion, the same as 
marks the outline of a cyst. The wave-line is very pronounced. 
The depth of the uterus is three inches. 



THE PATHOLOGY OF OYAKIAN TUMORS. 929 

Her general condition is tolerably good. She is dragged and 
exhausted with the weight and refilling of the tumor, but makes 
more complaint of the hernia than of anything else. Her mens- 
truation has been regular, but not too profuse. She felt so badly 
after the last tapping, that she declares it shall not be repeated, and 
insists upon an operation if only for the relief of the hernial pro- 
trusion, and for the sake of clearing up the diagnosis of the case, 
in which latter item she is more deeply interested than any one 
else can possibly be. I have told her most plainly and frankly that 
it is very doubtful if she has an ovarian cyst, and that it may be 
necessary to relinquish the operation a second time, or, in the event 
of malignant disease, to remove the womb. Of her own free will 
she asks for this expedient, and we have resolved to give the suf- 
ferer her only chance of life. 

The Operation. — The operation was made at noon of Tuesday, 
April 18, 1882, in one of my ovariotomy rooms in Hahnemann 
Hospital. There were present Drs. Comstock, of St. Louis; Pol- 
lock, of Galesburg; Scott, of Oneida; Crawford, Reynolds, and 
Ehle, of Chicago, who very kindly assisted. The incision was made 
at the side of the old cicatrix. Coming down carefully on what 
seemed to be a cyst-wall, a separation was made for an inch or two 
in order to determine if we were really within the peritoneum. 
This could not be decided until the fluid was withdrawn by tap- 
ping. The two layers of the membrane were separated from each 
other for a little, when I became satisfied that they both belonged 
to the peritoneum. The incision through this membrane was en- 
larged, and the abdominal contents were displayed in situ. There 
was no cyst of any description within the abdomen or the pelvis. 

The fluid drawn off was thin, of a light amber color, ascitic, and 
weighed thirty-four pounds. The only peculiarity about it was 
that two or three little whitish bodies, as large as a split pea, passed 
through the trocar while it was flowing. 

Further exploration disclosed two tumors, one on either side of 
the uterus. When these were brought to the lower angle of the 
incision, it was found that the only expedient left was the removal 
of the uterus with the masses attached. Supra-vaginal hysterect- 
omy was therefore performed. The broad ligaments were ligated; 
the uterus was carefully separated from the bladder, and detached 
all around. The abdominal portion of the cervix was treated as a 
pedicle, and the womb, with the diseased ovaries was cut away. 
Yery little blood was lost, no accident happened, the toilet of the 
peritoneum was carefully made, the old cicatrix was removed, and 
the umbilical hernia disposed of after the manner of Koeberle. 
The wound was closed and the patient put to bed, the operation 
having lasted nearly two hours. 

She re-acted fairly well, and soon became conscious, although 
the weakened condition of the circulation which had persisted dur- 
ing the operation still continued. The pulse was often scarcely dis- 



930 THE DISEASES OF WOMEN. 

cernible at the wrist, and, although she complained of being too 
warm, her hands and face kept cool, without any tendency to 
febrile reaction. At 4 P. m., the urine was drawn, the pulse was 
120, with some vomiting of frothy mucus. At 8 p. M. the tempera- 
ture was 98.5°, the pulse 120. She complained greatly of pain in 
the back and down the right crural nerve. 

These symptoms continued with slight variation. She had no 
good sleep; the urine was drawn every three hours; the bowels 
were slightly moved; she had nausea, but no more vomiting; the 
coldness of the face and of the perspiration were marked at inter- 
vals ; the temperature did not increase ; the left radial pulse could 
not be found, and the pain in the back increased. At 4 A. M., the 
carotid was poorly defined. The cardiac murmurs were distinct 
and regular, but soft and undulating. 

The respirations reached fifty per minute and were quite labored. 
She was sensible until within half an hour of her death, talking 
quietly of her approaching end, and thanking those about her for 
all that had been done for her relief. She sank quietly away at 
6:30 a. m., evidently from exhaustion, it being eighteen hours after 
the operation. 

An autopsy was held at the end of twenty-four hours, in the 
presence of those who had witnessed the operation ( excepting Dr. 
Scott), and also of Drs. Laning, Burnside and Glover. The incis- 
ion was re-opened and the abdominal cavity carefully examined. 
There were no signs of congestion, and no evidence of hemorrhage 
or any accident consecutive upon the operation. The ligatures 
upon the broad ligaments had not slipped; the pedicle was secure; 
the bladder had not been injured, and everthing was normal, 
excepting the peritoneum, which had formerly been mistaken 
for the wall of an ovarian cyst, and the presence of a quantity of 
ascitic fluid, wdiich had already poured into the abdominal cavity 
since the operation. 

6. ENCEPHALOID OF THE OVARY. 

In this form of ovarian cancer the contents of the cyst or cysts 
have been changed and degenerated into a peculiar, brain-like 
mass, whence its name. Both ovaries are usually involved in this 
variety of malignant growth, from which the uterus and the neigh- 
boring tissues are exempt. In this latter respect the encephaloid 
differs from kindred affections of the ovary. But the other symp- 
toms including the peritoneal dropsy, and the constitutional 
involvement are of the same serious character. The course of the 
disease is sometimes quite slow and insidious ; but at other times 
it is rapidly fatal. In exceptional cases, as with encephaloid tumors 
in other parts of the body, the growth is traceable to a traumatic 
injury, but usually hereditary influence can be readily detected. 



THE PATHOLOGY OF OVARIAN TUMORS. 931 

The most marked case of the kind that I have ever seen was one 
in which I made a double ovariotomy upon a patient of Dr. A. M. 
Eastman, in St. Paul, Minn., and in which there were forty pounds 
of ascitic fluid, while the tumor attached to one ovary weighed 
nine, and that of the other two pounds. The full history of this 
case was published, with a cut illustrating the same, in the Clin- 
ique, volume IV, page 439. 

I know of no more serious question than to decide upon the pro- 
priety of removing these encephaloid tumors of the ovary after 
having exposed them by an exploratory incision. My own rule 
has been to take them away if the pelvic adhesions are not so bad 
as to render it almost certain that the patient would die before the 
operation was finished. If the facts and the risks have been fully 
stated to the patient and to those most interested beforehand, and 
she or they insist that it shall be removed, I think we would do 
wrong to relinquish the operation while there was the least possible 
chance of recovery. 



LECTURE LVII. 

THE DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 

I. From Ascites. 2. From encys ed peritoneal dropsy. Case. 3. From pregnancy. 4, 
From extra uterine pregnane}'. 5. From uterine fibroids. 6. From fibro-cystic 
growths. 7. From physometra. 8. From distention and prolapse of the bladder, 
9. From enlargement and malignant disease of the liver and spleen. Case. 10. From 
tumors which are due to menstrual retention. 11. From renal cysts, etc. 

Within a fortnight I have shown you three cases of ovarian 
dropsy, and now I propose to teach you how to diagnosticate that 
disease from those with which it is often confounded. In two of 
these cases my diagnosis has been already confirmed, for the tu- 
mors which weighed twenty-seven, and forty-three pounds respect- 
ively, after I had removed them, were examined in the presence 
of the class. 

I. From ascites. — In the great majority of cases, abdominal 
dropsy is secondary upon some pre-existing chronic disease of the 
liver, of the spleen, of some portion of the digestive tract, of the 
kidneys, or, in rare instances, of the heart or lungs. In ovarian 
dropsy this rule is reversed, and the general ill health is the con- 
sequence of the development of the tumor. 

In ascites, if the patient lies upon her back with her knees 
drawn up, the abdominal tumor becomes flattened anteriorly, and 
" bulges," or spreads out laterally. The sides 
and flanks, as well as the front surface of the 
enlargement, except directly around the umbilicus, are dull and 
flat on percussion. Around the navel, however, there is a reso- 
nant sound in ascites. If she turns upon either side, there will 
be dullness upon that side, and resonance upon the other. But 
in ovarian dropsy the contour of the tumor is not changed when 
the patient changes her position. It is not flattened in front when 
she lies upon her back. Its margin is easily mapped out. The 
flanks are not distended. There is no dullness or bulging in the 
lumbar regions, but a resonance which is quite clear and charac- 
teristic, and which assures us that the intestines lie behind a cir- 
cumscribed sac, whatever its contents may be. This is so well 

932 



DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 933 

shown in the chart (Fig. 18) that T am quite certain you will 
remember it as a chief means of diagnosticating ovarian dropsy 
from ascites. 

In ascites the " touch" recognizes a fluctuation in the Douglas' 
cul-de-sac, which is lacking in ovarian dropsy. In ascites, also, 
the accumulation begins at the lowest and most 
dependent part of the abdomen, while in ova- 
rian dropsy the tumor usually commences in the right or the left 
hypogastrium, or in one of the iliac fossae. When it exists, ex- 
treme dropsy of the abdominal walls is almost always conjoined 
with malignant disease. Coincident oedema, especially of the feet, 
may exist from the first in ascites, but never occurs in ovarian 
dropsy except in the last stage of the disease. 

It should be remembered, however, that in quite a share of cases, 
more especially if the growth is malignant, or semi malignant, ovari- 
an tumors and ascites may coexist. The larger the accumnlation about 
an ovarian cyst the more suspicious the character of the tumor. 

Tapping is a useful means of diagnosticating between these two 
affections. Having withdrawn the serum in case of ovarian dropsy, 
we find that the solid or semi-solid tumor does 
not float out of reach as before the operation, 
but that it may now be quite readily examined and grasped by 
the hand through* the abdominal parietes. After tapping, there- 
fore, the size, shape, and location of this tumor can be so well 
made out that we need not confound it with such hypertrophy of 
the liver, the spleen, or of the mesenteric glands, as might have 
attended upon ascites. 

Concerning the time and mode of tapping, it should not be 

done during the menstrual period, neither directly after a meal, 

nor vet in your office. I once tapped a very 

pl " ,a" ? ai 'S e °y st with a sma11 trocar > and ve ^ carefully, 

in my office, and my patient sank almost imme- 
diately into a state of collapse from which it took me two hours 
to rescue her. Dr. Peaslee lost a case from tapping with a fine 
trocar. The instrument should consist of a small exploring 
trocar, or of the long slender needle of the aspirator, the use of 
which prevents the admission of air into the cyst when it has been 
wholly or partially evacuated. 

Beside its diagnostic value, tapping is sometimes of the greai- 



984 THE DISEASES OF WOMEN. 

est service in helping ns to decide upon the propriety, and indeed 
the necessity of an early operation. When you 
of T t b a e pping n ° StiCValUe succeed in drawing off a considerable quantity 
of fluid, which you are satisfied comes from an 
ovarian cyst, but have reason to believe that other cysts have not 
been reached, and cannot be emptied by the same puncture, the 
case is a compound one, and the clinical inference is that you should 
not keep on tapping one sac while the rest of the tumor is grow- 
ing, but that the whole mass should be removed as soon as 
possible. 

Some of you remember the case which was sent me a few weeks 
ago by Dr. L. Hall, of Minneapolis, Minn., in which, before she 
came into Dr. Hall's hands, the patient had been 
tapped nine times, with the removal of ninety 
quarts (by the husband's measurement) of a dirty wine-colored 
fluid. This had been done within eighteen months, but although 
the tumor had diminished, it had never disappeared in consequence. 

You saw that poor woman on the table ; you heard me give an 
unfavorable prognosis; you witnessed that I declined to operate, 
unless the husband and the patient took the whole risk; you saw 
her feeble condition, her courage, her cheerfulness, and her deter- 
mination not to leave this hospital until that tumor was removed. 
One of the sub-classes witnessed the operation, in which, through 
the most formidable and universal adhesions that I have ever seen, 
the tumor, weighing forty pounds and consisting of five large 
lobes, was removed. The next day it was examined before the 
whole class, and you saw the character of the contents of the four 
large sacs which had not been touched by the trocar, although an 
attempt had been made to open a second one. The smallest of 
these sacs had suppurated, and one of them contained more than 
a quart of dark, grumous blood. The large cyst, which had lain 
against the abdominal parietes, had no communication with the 
others. 

The patient lived only seven hours ; but the legacy left us was 
the conviction that if, when the trocar had told its story, the tu- 
mor had been removed, she might have gotten well again. 

It is important to remember that in ascites, after paracentesis, 
the re-accumulation of water is usually slow, while after the 
evacuation of an ovarian cyst, it is much more rapid and persis- 



DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 935 

tent. In one of my patients who had oyarian dropsy, from whom 
I withdrew many gallons of water, the abclom- 

Refilling of the s,c - j tumor was quifce ag larffe ag ever at the 
or cyst. 1 

end of the first week. 
In exceptional cases, however, ascites and ovarian dropsy co- 
exist, and both sets of symptoms are present at the same time in 

the same patient. The diagnosis between them 

is more difficult in case the cyst is unilocular 
than if it is multilocular, because in the former the abdominal en- 
largement is more rounded and uniform, and bears a closer resem- 
blance to that of ascites. 

II. From encysted peritoneal dropsy . — There is a form of ascites 
in which the accumulation of serum is localized by plastic peri- 
tonitis, and the tumor is limited, just as it is in hematocele. This 
sacculated form of peritonitis, which may occur in men as well as 
in women, may be traumatic, or it may be cancerous, or tubercu- 
lous; and it may follow an attack of: pelvi-peritonitis, or of 
hematocele. It is not of very frequent occurrence, but we have 
had three cases of the kind in the hospital in as many years. One 
of them was brought here by Dr. H. C. Thole, of D wight, 111., a 
description of which you will find in The U. 8. Medical 'Investi- 
gator for Sept. 1, 1877. 

The special signs of this form of dropsy are the lack of intest- 
inal resonance on the top of the tumor when the patient is lying on 
her back, and of the bulging in the flanks that is present in ascites ; 
the non-interference of respiration by the tumor; the highly albu- 
minous character of the fluid ; the constant peritonitis, and the 
usual co-existence of a grave cachexia. A very important sign 
also is that, when such a sac has been tapped, it almost never re- 
fills. This, indeed, is the kind of an " ovarian tumor" which is 
sometimes cured by electricity, and at others by internal remedies, 
when in point of fact it is no more an ovarian tumor than is a 
ease of dropsy of the knee-joint, or of the pleura. 

The only absolute test of encysted peritoneal dropsy is by tap- 
ping, and by the explorai ory incision. It has happened that cases 

of this kind have been cut down upon with the 

Case 

intention of performing ovariotomy, when there 
really was no other tumor than such as had resulted from this sac- 
culated form of peritonitis. On the fourth clay of September, 



936 THE DISEASES OF WOMEN. 

1874, I took my friends Drs. Dorion and Foster, and my brother, 
Dr. F. M. P. Ludlam, to a case which four physicians, two of 
whom were gynaecologists, had pronounced to be one of ovarian 
dropsy. The diagnosis was masked, and the patient was aware of 
the fact. We were prepared to operate in case it should be war- 
ranted after the exploratory incision was made. But a careful 
section of the peritoneum discharged the entire dropsical accumu- 
lation, and no sac or tumor could be found. The incision was 
closed, she made a good recovery, and now, when six and a-half 
years have elapsed, there has been no return of the difficulty. 

III. From pregnancy . — Pregnancy is self-limited, and its gen- 
eral history is so well defined that you might suppose there would 
be little risk of confounding it with ovarian 
fouTdeT 111 ^ C ° n " dropsy; but experience proves otherwise, for 
it has frequently happened to the surgeon to 
declare the patient ill with ovarian dropsy, when, in reality, she 
was pregnant, and upon making an abdominal section to find the 
foetus in utero, instead of an ovarian cyst within the cavity of the 
peritoneum. So frequent is this error in diagnosis, that it would 
not perhaps be extravagant to say that at least one-third of the 
cases of so-called ovarian dropsy, in which gynaecologists are con- 
sulted, prove to be cases of pregnancy. 

In ovarian dropsy menstruation is sometimes arrested. The 
reflex ovarian sympathies, which involve other organs, may simu- 
late those proper to gestation. The digestive 

Parallel symptoms. ,, J . . , „ ,° 

function is almost necessarily more or less im- 
paired. The mammary glands may be developed and become ten- 
der, as in pregnancy. The breasts may fill with milk, and even 
the areolae may become quite distinct. Usually, however, in ova- 
rian dropsy, unless both ovaries are diseased, the menses return 
irregularly, or are too frequent and copious. Last year I was 

consulted in a case of ovarian dropsy occurring 

A rare case. . -. . , . . , , 

m a wonan aged thirty-six years, who, by rea- 
son of a congenital absence of the vagina, had never menstruated. 
The patient's age will sometimes assist in diagnosticating ovarian 
dropsy from pregnancy. 

In general, we say that in pregnancy the abdominal tumor has 
some peculiarities of situation and growth which may perhaps 
serve to distinguish it from an ovarian enlarges r^t. For exam- 



DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 937 

pie. it has originally been intra-pelvic; it ascends gradually or 
more rapidly, as the case may be, at about the 

Location and growth. , . 

fourth month, and its globular outline is easily 
recognized by palpation. It it deviates to either side of the 
median line, its margin is smooth and well defined. From the 
fourth until the eighth month it grows from below upwards. It 
assumes the form of a general swelling, and is never described by 
the patient as a " lump" in her side or elsewhere. 

But we must not forget that both these affections may escape 
observation or suspicion until weeks or even months have elapsed 
before our advice is sought. Under these circumstances, we shall 
be compelled to rely upon other signs in order to separate them 
and to treat them properly. 

The " touch" may aid very greatly in the diagnosis. In preg- 
nancy, after the fifth month, and more especially in multipara, 
the uterine cervix is considerably softened, 
in^thTates!^ ""^ swollen, and compressible, and the external os 
uteri patulous. In uncomplicated ovarian dropsy 
its shape, size and cartilaginous character remain unchanged. In 
pregnancy, at or after the fifth month, you would expect to find 
the cervix at the superior strait, not far from the promontory of 
the sacrum. And, although it is frequently drawn up and either 
ante-flexed, or displaced toward the affected side in ovarian dropsy, 
still its location will in most cases not differ materially from that 
of the unimpregnated uterus. If the internal os uteri was open, 
and the finger did not come into direct contact with the mem- 
branes, the placenta, or with some part of the foetus, the woman 
could not be pregnant. The easy introduction of the uterine 
sound, and its ready passage to the fundus uteri, would also enable 
you to exclude pregnancy from the list of probabilities. But the 
sound should not be used unless it is manifest that, if the patient 
is pregnant, her " term" is very near. 

The uterine souffle is so equivocal a sign of pregnancy that, 
except as confirmatory, we cannot place much dependence upon 
it; for it has been found that it does not arise, 
unre!iaWe ine S ° Uffle as was once supposed, from ai i increased devel- 
opment of vessels, and an augmented circula- 
tion of blood at the site of the placenta and through it. In other 
words, it is not necessarily connected with the utero-placental cir- 



938 THE DISEASES OE AN OMEN. 

culation. It may be present in fibroids, in uterine cancer and 
hypertrophy, in tumors within the broad ligament, in aneurism 
ot the abdominal aorta, in case of a tumor pressing upon the iliac 
arteries, in sub-involution of the womb after delivery, and also in 
ovarian enlargement with or without dropsy. 

If you are fortunate enough to detect the foetal heart-sounds, 

all dcubt will be at an end. But, although this will afford you an 

unequivocal sign of pregnancy, if you can rec- 

The foetal heart-sound j {t ^ ^ not however be wise to 

unequivocal. ^ ■ . 

conclude that your patient was not pregnant 
simply because, after repeated trials, you failed to find it; for it 
might be so distant, indistinct and obscure, or so modified, that 
you would not know it from other sounds. Or the position of 
the foetus in utero might be such as to render it quite impossible 
for you to hear it at all. 

In advanced pregnancy, if the position of the child is favorable, 
and the abdominal walls are thin, it is sometimes possible to recog- 
nize the head, or the extremities of the foetus, by palpation. 
Quickening, if it were genuine, would confirm this condition. And 
yet it has happened that the irregular outline of the proper ovai- 
ian tumor has been mistaken for that of the child ; while the move- 
ments of the foetus in utero may be counterfeited in various ways. 

It is, therefore, more difficult to diagnosticate ovarian dropsy from 
pregnancy than you would have supposed. Sometimes they co- 
exist. In very rare cases the dropsy is contingent upon gesta- 
tion, and disappears after delivery. 

If you can not otherwise determine the rliagnosis, it will be best 
for you to proceed as in other cases where pregnancy is possible, 
id est, to wait until the proper limit for that 
ofTagno'sis! 1 6lement condition has passed, for, ordinarily, there need 
be no haste in deciding. If the woman is preg- 
nant, the tumor will not sensibly increase in size, or develop in 
an upward direction, after eight and a half months. When ten 
or twelve months have elapsed since the swelling was first noticed, 
it is tolerably certain that there is some kind of a tumor present 
which would be found in case of extra-uterine pregnancy, in which 
the foetus might be indefinitely retained. But this form of ges- 
tation is so rare as scarcely to deserve notice in this connection. 
In women, as you know, the natural limit for pregnancy is nine 



DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 93i> 

months, while the average duration of ovarian dropsy is about 
three years. 

IV. JPrmn extra-uterine pregnancy, — In the great majority of 
cases extra-uterine fcetation terminates by a rupture of the cyst, 
and pelvic hematocele, at or before the fourth month. I have 
already cited you a remarkable instance of this kind (page 428). 
Under these circumstances there is little risk of confounding the 
tumor with ovarian dropsy. But, when the sac has not burst, 
and the foetus has become encapsuled, more especially if it has not 
been mummified, but has developed and remained plump, with a 
large amount of serous fluid around it, it may be very difficult to 
diagnosticate it from ovarian dropsy. 

If you will remember that, although its cavity is not necessarily 
enlarged, the tissues of the uterus are softened and dilated in this 
form of pregnancy ; that the finger can be passed into it for the 
purpose of conjoined manipulation; that cases of extra-uterine 
pregnancy which are extended in this way are almost, always of 
the tubal variety, which makes the tumor accessible from the side 
of the uterine cavity ; and that extra-uterine ballottement is there- 
fore available to detect a floating solid just outside of the uterus, 
it may assist you greatly. 

Tapping with the ordinary trocar in such a case is murderous, 
for in extra-uterine pregnancy, unless there has been a great deal 
of adhesive inflammation, the walls of the sac will not collapse and 
close when that instrument is withdrawn, as they do after the needle 
of the aspirator. The consequence is an overflow of its vitiated 
contents into the peritoneal cavity, and death from sepsis. You 
will therefore take the aspirator in preference, and while its slen- 
der trocar is being passed, or afterwards, use it carefully as an 
exploring needle by which you may recognize the bony parts of 
the foetus, if there is one. Simon's rectal exploration is a danger- 
ous expedient on account of the risk of rupturing the extra- 
uterine sac, which is usually very delicate; and an unsatisfactory 
one, because, unless the foetus is mummified, it gives no positive 
evidence, and therefore could not help us to distinguish this form 
of pregnancy when it is most likel} 7 to be confounded with ovarian 
dropsy. 

V. From uterine fibroids. — Although ovarian dropsy may be 
accompanied by irregular menstruation, in which the flow may be 



940 THE DISEASES OF WOMEN. 

either too frequent or too copious, or both, nevertheless we can 
not properly say that patients having this form 

Haemorrhage. r- -, V • i u t 

ot dropsy are prone to uterine haemorrhage, in- 
deed, the dropsical and the hemorrhagic diatheses are at antipodes, 
and seldom or never exist in the same person. But the hypertro- 
phy of the muscular structure of the womb, which is pathological 
and not physiological, or which, in other words, does not pertain 
to the development of the gravid uterus, but which follows abor- 
tion or labor, or an attack of metritis, is in the majority of cases 
attended by a more or less protracted and alarming menorrhagia. 
Statistics show that only nine per cent, of the cases ot ovarian 
dropsy are accompanied by uterine haemorrhage ; while as large a 
proportion of cases of uterine fibroids as seventy per cent, are 
marked by this symptom. This estimate does not include those 
extra-mural or sub-peritoneal fibroids from which such a haemor- 
rhage would be impossible. 

Whenever, therefore, you have a patient who is subject to con- 
siderable or continuous flooding- which begins and ceases without 
any special relation to "the month," and more particularly if she 
is not pregnant, and there is present a pelvic or abdominal tumor 
of considerable size, you will have reason to suspect that she has 
one or more uterine fibroids. In that case the tumor will most 
.probably be clue to hypertrophy of the uterine muscular tissue, 
while the haemorrhage is a species of critical outlet or safety-valve 
for the excess of blood carried thither. 

In uterine fibroids the tumor is hard and movable. Its mobility 
is diagnostic. When you can feel that a motion is imparted to the 

Consentaneous mobility whole maSS h Y a bloW from the &*&*. U P 011 the 

of the uterus and the posterior wall of the cervix-uteri ,as in ballotte- 
ment, or by introducing the uterine sound can 
lift the organ and satisfy yourself by the hand placed over the 
abdominal parietes that the entire tumor moves along with it, 
there can be little doubt of the presence of a uterine fibroid, 
Sometimes, however, it may happen in this form of neoplastic 
growth that the womb may be immovable, as it is in scirrhus ol 
that organ. 

The distance to which the sound will enter the womb is also 
significant. As a rule, if it passes in more than three inches the 
uterus is said to be enlarged ; and enlargement of the uterine 



DIFFERENTIAL DIAGNOSIS OF OVARIAN DROPSY. 941 

cavity is one of the most certain and constant signs of these same 

fibroid growths. In uncomplicated ovarian 
cavitT 11 ° f ^ Uterine ^opsy, if the womb is sometimes elongated, it 

is in consequence of its displacement, and of the 
unnatural pressure of the ovarian tumor upon it. The manifest 
changes in the length and size of the uterus which are present in 
a case of fibroids, do not properly belong to the clinical history 
of ovarian dropsy. 

Fibroids are of slow growth; and so, also, are ovarian tumors, 
in the early stages of the same. But ovarian tumors sometimes 

develop rapidly from the first, or having existed 
growth™ rapidlty ° f lor some months and grown very slowly, they 

suddenly fill the abdomen and give rise to much 
suffering and discomfort. Uterine displacements and leucorrhcea 
form a natural and almost necessary part of the history of fibroids, 
while they are generally absent in ovarian dropsy. 

VI. trom fibro-cystic growths — Those fibroids which are 
attached to the exterior surface of the womb, and which lie be- 
neath its peritoneal investment, sometimes undergo cystic de- 
generation. In this case the tumor, which may include a number 

of these degenerate fibroids, is likely to become 

'of such size as to fill the abdominal cavity, and 
to be mistaken for ovarian dropsy, ascites, and even for pregnancy. 
So close is this resemblance, that in many cases the most skilful 
practitioners of this specialty have been unable to diagnosticate a 
fibro-cystic from an ovarian tumor, before making an exploratory 
incision. Fortunately, however, this species of fibroid is compar- 
atively rare. 

Dr. Routh's statistics show that in only three out of eighteen 
cases of fibro-cystic tumor was there any menorrhagia. Spencer 

Wells has several times diagnosticated thepres- 
£%££££? ™™™ of these fibro-cysts of the uterus by the es- 

cape through the trocar on paracentesis, of a thin 
serum containing from five to fifteen per cent, of blood, with 
which it is so intimately mixed as not to separate from it until 
after standing for some hours. 

Without enlarging upon these and other points that will help 
you to diagnosticate ovarian dropsy from fibro-cystic growths, I 
will refer you to a valuable classification of the more prominent 



^42 THE DISEASES OF WOMEN. 

symptoms arranged by Dr. Charles C. Lee, and published in the 
"JST. Y. Medical Journal;' Vol. XIV., p. 474. 

IN OVARIAN CYSTS. IN FIBRO-CYSTS OF THE UTERUS. 

1. Disease may occur at any period, even 1. Scarcely ever occurs under thirty— gen-. 

before puberty. erally from forty to fifty. 

2. Development rapid — usually under two 2. Development slow — generally over two 

years. years. 

3. Aspect of face unaltered, if the general 3. "Facies uterina" generally marked; 

health be fair. expression anxious and dejected. 

4. Fluctuation equable over the whole sur- 4. Fluctuation confined to certain regions 

face of the tumor. —generally to upper portion, while 

the lower is hard and dull. 

5. Vaginal examination shows little dis- 5. Va«inal exrminat on shows the uterus 

placement of the uterus — the mass high up or displaced. The mass either 

smooth and distinct from the uterus. not detected or continuous with the 

uterus. 

6. Mobility of the uterus independent of 6. Independent mobility of the womb con- 

the tumor from the beginning — pelvic fined to the last stage of the disease, 

adhesions rare. Pelvic adhesions common. 

7. Tapping causes complete collapse of 7. Tapping causes only partial collapse, 

unilocular cysts ; in polycystictumors, leaving the base of the tumor firm and 

it reveals the endocysts. indurated. 

8. The fluid is clear, straw-colored, serous; 8. The fluid is either brownish, bloody, 

or viscid, clear, mucoid, and albumin- sero-purulent, or muddv ; or thin and 

ous. yellowish, containing shreds of lymph 

or of cholesterin. 

9. When exposed by gastrotomy the sac is 9. The exposed sac is dark, vascular, thick, 

pearly blue, or white and glistening; and frequently fasciculated with 

but rarely vascular. fibrous bands. 

VII. From physometra. — Distention of the womb with gas is 
not very likely to be confounded with ovarian dropsy. If the 
abdominal enlargement, upon which I place my hand, is due to 
such a cause, the swelling will be tympanitic on percussion over 
its whole extent, instead of dull and flat as in dropsy. And then, 

too, the tumefaction could be very readily re* 

Empty the uterus. _. . . 

moved without resort to such a severe opera* 
tion as ovariotomy; for we could pass a male catheter through 
the cervix uteri and discharge its contents in a very few moments, 
Physometra is always attended by more or less 
troublesome hysterical manifestations, which do 
not pertain to ovarian dropsy, and which can be dissipated by 
means of an anaesthetic. 

VIII. From distention and prolapse of the bladder. — The skil- 
ful use of the female catheter and of conjoined external and in- 
ternal manipulation, would enable you to decide between either 
of these affections and ovarian dropsy. 

IX. From enlargements of the liver and spleen. — Hypertro- 
phy of the liver is almost invariably associated with chronic dis- 



DIFFERENTIAL DIAGNOSIS OF OVAKIAN DROPSY. 943 

ease of that viscus. The form of dropsy that attends it is ab- 
dominal. When effusion has taken place into 

Physical exploration. , . , .,, ., , 

the peritoneal sac, you will recognize the phys- 
ical signs of ascites. The margin of the enlarged liver, which 
is well defined, the absence ot uterine complication, which is 
suggestive, the digestive and constitutional disorder, which are 
significant from the outset, and the general contour of the tumor, 
will help you to differentiate between enlargement of the liver and 
the presence of one or more ovarian cysts. 

In October, 1879, I was called by my friend, Dr. A. W. Burn- 
side, of Belvidere, 111., to a patient whose former physician 
had declared that she had an ovarian tumor. Dr. B. o-ave no 
opinion, but desired my diagnosis and my view concerning the ex- 
pediency of an operation. I decided the case to be a malignant 
hepatic tumor, and, of course, made no operation. In a little 
while the woman died, and a careful autopsy afforded a remarkable 
specimen of cancerous liver, which through the kindness of Dr. 
Buruside's pupil, Dr. W. A. McDowell, was shown to the class. 
The record of her case is as follows: 

Case. Mrs. — , set 52, is the mother of two children, the youngest 
of which is tweuty-two years of nge. Two years ago she began 
to be troubled with indigestion, and although she was under con- 
stant treatment, it gradually grew worse. About four months 
before her death she became unable to retain any food upon her 
stomach. In the early part of August there was observed a small 
abnormal growth near the umbilicus, which grew slowly until 
iibout three weeks before her death, when it grew very rapidly, 
with an aggravation of all her other symptoms. At times she 
suffered very severe burning pains which she referred to the 
stomach. Her feet and limbs became very dropsical, and her com- 
plexion finally became highly jaundiced. Almost the whole abdo- 
men was filled with the tumor, which, at the post-mortem, weighed 
eleven and a half pounds. The gall-bladder was full of gall 
stones, three of which were as large as a hickory-nut. There 
were extensive adhesions to the transverse colon, and also to the 
stomach. 

So, also, with an abnormal development of the spleen. The 

constitutional symptoms which accompany it are characteristic. 

One or another of the forms of aome, and im- 

Leucocytosis. . . 

pairment of the quality of the blood, with leu- 
kaemia and perhaps anaemia also, will serve to identify this lesion. 



944 THE DISEASES OF WOMEN. 

The exploratory incision is the only means of an absolute diag- 
nosis in some cases of this kind, and it should be very carefully 
made. 

X. From tumors caused by retention of the menses, and of 
faecal matter. — The former would depend upon an imperforate 
hymen, atresia of the vagina, or of the uterine cervix, or of both 
these passages, or upon obliteration of the neck of the womb by 
some flexion or deviation of the organ, or by some foreign growth 
which served to block up its outlet. In either case the "touch," 
and the introduction of the uterine sound, would discharge the 
menstrual deposit and remove the tumor. Such an expedient 
would be useless in real ovarian dropsy. 

If there was excessive faecal accumulation, the previous history 
of the case, and, more than all besides, a careful examination of 
the tumor, would disclose the difference between it and the dis- 
ease we have under consideration. The tumor would be hard 
and irregular, and nodulated to the feel, and could be traced along 
the course of the rectum and the colon. Emptying the bowel by 
enemata of oil, castile-suds, or of a similar solvent, would settle 
the question most effectually. 

XL From renal cysts and floating kidney. — The' only form of 
renal cyst that resembles an ovarian tumor of considerable size is 
the sac in exceptional cases of hydronephrosis. The fluid con- 
tained in such a tumor may reach thirty pounds. The distinctive 
peculiarity of that fluid is that it always contains urine with pus 
or albumin. Serous and hydatid cysts of the kidney which may 
resemble the smaller ovarian cysts, can be known from them by 
tapping. In renal growths the tumor develops from above down- 
ward and may be moved toward the corresponding lumbar region. 
This rule applies especially to the migratory kidney, which, in 
cases cited by Atlee and others, has frequently been mistaken for 
a small ovarian cyst. 



LECTURE LVIII. 

EXPLORATIVE METHODS OF DIAGNOSIS. 

I. The exploratory incision; history of ; practical indications for; precaution; mode of mak- 

ing; suitable cases for; is sometimes curative: case; detailed instruction, case; practical 
results; practical rules for. 

II. Tapping; as a means of diagnosis; not curative; mode of operating; examination of the 
fluid that is drawn; the form of the abdomen after; tapping as a palliative; a dangerous 
expedient; case ; the sources of danger from; how it may increase the risks after ovariotomy. 

I. THE EXPLORATORY INCISION. EXPLORATIVE LAPAROTOMY. 

Although the usual methods of diagnosis in ovarian and other 
abdominal tumors were carefully considered in our last lecture, 
the subject is not exhausted until I have spoken of the explora- 
tory incision. Laparotomy, by which is meant a section of the 
abdomen, belongs to diagnosis, is its last resource and its final 
appeal in doubtful cases. 

The deliberate opening of the abdominal cavity for the purpose 
of making a precise and a perfect diagnosis in 
History of. the case of a contained tumor, was first practised 

by Walne in 1842. For more than forty years 
in pre-antiseptic days, it was unpopular, but now there is such a 
reaction in its favor that it bids fair to be abused unless the indi- 
cations for its employment are carefully considered. This is what 
is called the abdominal section, the exploratory incision, gastrotomy, 
or more properly, an explorative or a diagnosticial laparotomy. It 
should not be made carelessly, without hesitation, or without the 
strictest antiseptic precautions. Nor should it be done until the 
patient, or her family, or both have been fully apprised of the 
object in view, and of the possibility that nothing more than an 
incision may be prudent or permissible. Let 
Precaution. them understand that it is a pre-operative exped- 
ient which is intended to finish an imperfect and 
an incomplete diagnosis ; that it is not made for the sake of cutting, 
or from mere curiosity; and that its design is to expose the tumor 
to the direct touch and to sight in order that the question of its 
removal may be satisfactorily settled. 

945 



946 THE DISEASES OF WOMEN. 

'There is no doubt that a good deal of rashness and a certain 
amount of incompetence is sought to be concealed by the practice 
of 'exploratory incisions.' No incision ought to be merely explor- 
atory; at the utmost, it ought to be ultimately diagnostic in a case 
of extreme doubt and difficulty. * * # * Before submit- 

ting our patient to what, after all, is a serious operation and a try- 
ing illness, we ought again and again to return to the examination of 
the disease, read and re-read the exhaustive history, and decide 
only after having done this. At different examinations the mind 
focuses its attention on different points, and travels in different 
directions; and each examination may give us new information. 
The help of a skilled friend is always valuable, but too much 
weight must not be given to it. Responsibility begets trustworth- 
iness; the man who operates is the man who must diagnose, and 
additional acumen is given to his powers by the heavy responsi- 
bility that waits upon their fruition." (J. Greig Smith). 

This form of laparotomy has a threefold value: (1) to enable us 
to complete the diagnosis by a digital and a visual examination of 
the tumor, and of the pelvic and the abdominal organs that are 
involved; (2) to enable us to decide upon the expediency and the 
propriety of an operation, and (3) that we may determine intelli- 
gently what particular operation shall be made. 

1. To complete the diagnosis by a digital and visual examina- 
tion of the tumor and of the pelvic and of the abdominal organs 
that are involved. — After having cleansed the abdominal integu- 
ument with the same antiseptic solution that you 
Mode of making, intend to use internally, the incision is carefully 
made, just as in ovariotomy. And, no matter 
what the location or size of the growth or of the obstruction, it 
should be made in the mesian line. This drawing on the black- 
board (Fig. 175), shows the lines of incision that have been tried, 
or adopteii by various gynecologists; but the usual one is the ver- 
tical and median incision chosen by Mauricean for the Cesarean 
section. The wound should not be more than from two to three 
inches in length, just sufficient to admit the passage of two, or at 
most of three fingers; and all hemorrhage should be stopped be- 
fore the peritoneum is opened. 

When you are ready to open the peritoneum yo a may recall the 
maxim of my old friend, Dr. Palmer, to "look for the worst, hope 
for the best, and take what comes." For when it is properly made, 



EXPLORATIVE METHODS OF DIAGNOSIS. 



947 



the incision holds the key to all cases of doubt. It leads us to the 
seat of trouble in the most direct manner, and 
Caution. cannot be harmful if it is done with delicacy and 

not with a rough dispatch. But too much manip- 
ulation, or too long exposure of the parts may be very mischiev- 
ous. Once satisfied with the diagnosis, and of the impossibility 
of removing the tumor with safety and success, we must stop! It 
may be, and it usually is much harder to stop than to go forward, 
but we must not forget that a little rashness and traumatism might 
cost the poor woman her life. So I shall ask you to verify by sight 



USUAL LINE 



ATLEE 




DOPLSEY 
ST5RER 



Fig. 175. The various lines of abdominal incision. 

only what I may find in this case, for it has been well said that 
"death is a severe penalty to pay for the perfection of diagnosis." 
A recent author is justly emphatic when he says: "Having 
made this exploratory incision we must not be too rash in convert- 
ing it into an operative one. We ought to be sure, before inflict- 
ing the slightest injury upon the growth, that we can remove it. 
To have been forced to submit the patient to exploration by incis- 
ion, is grievous enough ; but to have added thereto additional risks 
from sheer meddlesomeness, is unpardonable. Difficulties and 



948 THE DISEASES OF WOMEN. 

dangers, legitimate and unavoidable, are numerous enough, in all 
conscience, in abdominal surgery; let us not to these add risks that 
are illegitimate arid avoidable." (J. Greig Smith). 

The conditions in which doubts are apt to exist are various. Not 
only is it impossible in certain cases to decide 
suited 8 tc? which {t is by any other means whether the tumor is uter- 
ine, Fallopian, or ovarian, renal, splenic, hepatic, 
mesenteric, or pancreatic; what are its anatomical relations, and 
whether its attachments are slight or extensive, manageable or 
not; but without this expedient we may be equally in the dark con- 
cerning its malignancy. If a fenestrated opening can be safely 
made and closed again we shall have followed the rule of reserv- 
ing the instrument of greatest precision in diagnosis until the 
close of the examination. 

It completes the diagnosis, and literally opens the way for relief 
in pelvic abcess, pelvic hematocele, puerperal peritonitis and cel- 
lulitis with sero-purulent accumulations, in al] forms of salpingitis, 
and in case of cystic or sclerotic degeneration of the ovaries. It 
is essentially conservative, the same as the abdominal incision for 
gun-shot wounds of the intestines, or for the direct examination 
of the stomach, or of the gall-bladder. And not only will its care- 
ful employment with good surroundings result in the saving of 
human life in certain cases, which were supposed to be beyond 
relief before the daylight was let in upon them, but the specialist 
who makes these incisions with comparative frequency will there- 
by learn to recognize and to differentiate all sorts of abdominal 
tumors with a greater degree of aptness, precision and certainty. 
It ought to be added to the reasons given by Dr. Bantock in his 
' ; Plea for Early Ovariotomy." 

You will occasionally be surprised to find that the exploratory 
incision, pure and simple, is absolutely curative, 
is sometimes curative. The best examples of this kind occur in tuber- 
cular peritonitis and encysted peritoneal dropsy, 
in chronic peritonitis, and in the dysmenorrhea of highly hysteri- 
cal subjects. In the former the good result is akin to that which 
follows a free incision of the tunica vaginalis testes for the radical 
cure of hydrocele ; but in the latter the mental shock produced by 
the idea of having undergone a serious operation (where nothing 
was removed) has so changed the clinical expression of the case 
that the hysterical symptoms will have disappeared. 



EXPLORATIVE METHODS OF DIAGNOSIS. 949 

2. To enable us to decide upon the expediency and the propriety 
of an operation. — When the indications for explorative laparot- 
omy were less clearly established than now, it was a very common 
thing to speak of a case in which the incision had been made and 
nothing further done as an unfinished or an incomplete operation. 
Strictly speaking, it is not an operation any more than is tapping 
with or without the aspirator, and in the great majority of cases it 
is much more satisfactory. Dr. Sims is reported to have said in 
1872: "I never know exactly what I am going to find when I gain 
admission to the abdominal cavity." And Tait says very express- 
ively: "Sometimes I now begin an 'exploratory incision' and end 
it as an 'ovariotomy,' while formerly I used to start an 'ovariotomy' 
only to end it as an 'exploratory incision.' " There is only one risk 
to a beginner in this, that he will have to learn when to stop at the 
mere exploration. To attempt the removal of a tumor and not be 
able to finish it, is the most fatal of all proceedings, and therefore 
the list of incomplete operations should always be a short one." 
The operation is not an unfinished one unless you have really tried 
to remove a tumor and have failed to do so. 

The following case will serve as an illustration. The patient 
was sent to my clinic by Dr. A. H. Van Voorhis, of Dakota, April, 
■20,1887: 

Case 20001. — Mrs. , aged forty-eight, the mother of five chil- 
dren, was married at twenty-three, was always well until after the 
birth of her last, a boy, fourteen years ago. At that time she came 
near dying from inflammation of the right ovary, but she recovered 
in eight weeks. Then she had one severe shock at the death of 
her mother, and another by her husband's failure in business. 
Since the last mishap she has been obliged to work very hard, and 
has suffered much from ovaralgia. Two years ago while sitting at 
the table writing, and without previous warning, she suddenly felt 
what seemed to her like a foetus rising from the pelvic cavity to 
the right hypochondriac region. From this time she supposed 
herself to be pregnant; yet the menstruation continued regular 
and normal. 

In the autumn of 1885 the signs of pregnancy disappeared and 
her weight increased from about 140 to 180 pounds. In May, 1886, 
she had typho-malarial fever, from the effects of which she has not 
fully recovered. During the first fortnight of this illness she lost 
thirty pounds in flesh, and her emaciation disclosed a hard but 
painless tumor about the size of the fist, and located in the right 
hypochondrium. She was for some time in the care of a German 
physician, who promised to discuss this tumor by absorption. He 



950 THE DISEASES OF WOMEN. 

said: "I make you strong, the tumor he grow faster; I make you 
weak, the tumor he no grow!" When she had lost in all about 
eighty pounds in weight, Dr. Van Yoorhis was consulted. He 
found an abdominal enlargement as in a six months' pregnancy; 
she was exceedingly weak and prostrate, the feet and ankles were 
swollen, the bowels were bad and the digestion was very much im- 
paired. She gained strength slowly, and finally determined, with 
all of a good, brave woman's pluck, to make the long journey 
hither for an operation. 

The patient being properly anaesthetized and everything in read- 
iness the incision was made through the linea alba. The hemorr- 
hage being under control and the wound perfectly clean and asep- 
tic, the peritoneum was opened. This disclosed a cancerous 
mesentery which was studded with hard, whitish deposits, and 
some of the veins of which were as large as one's little finger, full, 
turgid, and ready to burst. Beneath this envelope, which was 
quite adherent over nearly the whole surface of the tumor, was an 
immovable mass of cancerous infiltration which involved the intes- 
tines and the neigboring viscera. To the right of the incision was 
a cyst of the size and form of a goose-egg, which could be felt but 
for which no pedicle could be found. It was this which had been 
recognized as a small, knob-like protuberance by external palpa- 
tion. The malignancy of the growth was manifest. The diagno- 
sis being fully established, no attempt was made for its removal. 
The greatest care was taken not to wound any of the' vessels; the 
peritoneum was closed with the continuous catgut suture, and the 
external wound united with silver wire. 

The tumor that I showed you at my clinic on Saturday last, a 
condensed multilocular cyst of the ovary, had a history which 
illustrates the value of this form of exploration, when properly 
made and followed up with the appropriate operation. The woman 
from whom it was taken was a patient of Dr. J. E. Morrison, of 
Urbana, 111. The most careful examination by the usual means 
did not enable us fully to make out the diagnosis. The probabili- 
ties were largely in favor of its being an uterine fibroid. An 
explanation to this effect was made to the husband of the patient, 
and with the assistance of Dr. Morrison and Dr. O. M. Baird, of 
Champaign, I made the abdominal section prepared to finish with 
an ovariotomy, or a hysterectomy, or whatever else should be 
required, ivhen we had completed the diagnosis. The tumor was 
turned out, its pedicle secured, the wound closed and the patient 
left in good condition.* 

There are cases in which an explorative laparotomy brings great 

*This patient is now well again. 



EXPLORATIVE METHODS OF DIAGNOSIS. 951 

relief with little comparative risk, even where it does not promise 
anything in the way of a radical care. I had such a case a week 
ago in Kendallville, Ind. Its clinical history, which was kindly 
prepared for me by the attending physician, Dr. W. M. B. Olds, 
is as follows: 

Case. — On April 27, 1886, I was called to see Mrs. , aged 

forty-two. She was married but had never borne children. She 
complained of gastric trouble ; a dull dragging in the epigastrium ; 
yawning; coldness of the extremities, with a burning, gnawing, 
cramp-like pain in the stomach, extending upward through the 
chest and throat. She had great dyspnoea, with laborious action 
of the heart, and a heaviness in the right hypochondrium, with 
headache and depression of spirits. There was a dragging sensa- 
tion in the pelvis and pressure on the rectum while standing; ex- 
treme constipation; the skin and eyes were yellow; sour eructa- 
tions; the tongue was coated yellow, pasty and dry, and the urine 
was dark brown and scanty; the menses had ceased; the family his- 
tory reveals no hereditary taint. She has been suffering for sev- 
eral years with the foregoing symptoms. Nux and Chelidonium 
were prescribed with good effect which lasted for a few days only. 
Under Coloc. and Apis, mel the flatulence subsided, and the urine 
cleared up for about three weeks, when the symptoms returned. 
July 1 she was very much bloated; the abdomen and stomach were 
highly distended ; she had extreme pain, palpitation, dyspnoea and 
a decided nervous prostration. Examination revealed the char- 
acteristic diagnostic symptoms of ascites, and I decided to perform 
paracentesis. On the 27th of July, 1886, 1 removed fifty-five pounds 
of fluid. She rallied readily and was about the house until August 
25, when I took thirty-two pounds of fluid. This was repeated 
September 9, and each month following until November, when she 
was tapped every ten days until January, 1887, after which it be- 
came necessary to repeat it every seven days. After February she 
was tapped every four days. She suffered no inconvenience from 
these repeated tappings. She would keep her bed one day before 
the operation and then would be about her house the following 
morning. After the first tapping her general health seemed to 
improve. She was free from constipation, the appetite was good 
and she gained in weight. She was tapped forty-three times in all, 
and about 700 pounds of serum were taken away. 

In August, 1886, she first complained of ovarian pains and 
shortly after I discovered a tumor which gradually developed 
until it was thought best to consider the propriety of its removal 
by an operation. 

Physical examination showed that the uterus was firmly anchored, 
and that quite a mass was lying at the left lateral cul-de-sac, in- 
volving the broad ligament and probably the ovary also. At the 
right of the uterus there was a similar growth but of smaller size. 



952 THE DISEASES OF WOMEN. 

In the right side of the abdomen there was a movable tumor which 
felt like a cystic ovary floating in ascitic fluid. The exploratory 
incision was determined upon on the theory that both the right 
and the left-sided growths at the roof of the vagina might possi- 
bly be impacted, and therefore removable; that at least the float- 
ing tumor might be taken away, and that its removal and the incis- 
ion of the peritoneum might, for a time at least, have the effect to 
arrest the rapid ascitic effusion. With the assistance of Dr. Olds 
and Dr. N. G. Eieff, of Albion, Inch, the incision was made after 
full preparation for any final procedure that might be necessary. 
The lateral growths were found to be due to cancerous infiltration, 
and were therefore let alone; but the floating tumor proved to be 
a cysto-carcinoma of the right ovary. It was removed and weighed 
ten pounds. I showed it to you and explained its peculiarities on 
Wednesday last. That patient is now at the ninth day and is sail- 
ing along without any troublesome symptoms.* 

Although the operation ends with the incision, the discharge of 
the ascitic fluid, and the cleansing of the abdominal cavity, the 
excellent results obtained from laparotomy in tuberculosis, and in 
encysted dropsy of the peritoneum make it one of our most valued 
resources. 

3. To determine intelligently what particular operation shall be 
made. — In its recent progress abdominal surgery has -developed a 
variety of resources which cannot be properly applied in making 
a radical operation until the indications for their employment are 
plainly presented. Who ever has opened the abdomen very often 
in the living subject knows that every incision made through its 
walls is really explorative. Some one has said that "nothing is 
easier than to be wise after the event." When we have found the 
tumor, and determined its nature, its seat, its attachments, and the 
possibility as well as the propriety of its removal, it becomes a 
very serious question as to what form of surgical procedure is best 
suited to the case in hand. The fact that the intervening parietes 
are out of the way facilitates matters and enables us to do just what 
is most clearly indicated, and in the best manner, for the welfare 
of the patieni. 

Without a preliminary laparotomy the general surgeon could 
not decide what he would do in a case of visceral injury within 
the abdomen. He first finds the lesion and then fills the varying 
indications, whatever they may be, as carefully and as skilfully 
as possible. This was the way that our friend, Dr. W. E. Green, 

*In a month there was a slight return of the ascites. After recovering from the operation, 
and having been about her house and out of doors for some time, she took a severe cold that 
terminated in an attack of pleurisy from which she died. 



EXPLORATIVE METHODS OF DIAGNOSIS. 953 

of Little Rock, Arkansas, proceeded in making the first successful 
laparotomy that was ever made for pelvic abscess.* This is the 
way to proceed in those cases of adherent retro-displacements of 
"the uterus in which salpingotomy, oophorectomy, or hysterorrha- 
phy, is requisite to the cure of the abnormal condition. And this, 
with proper precautions, is the proper course to take, not only in 
cases of abdominal tumor which can not otherwise be clearly iden- 
tified and intelligently operated upon, but also in such cases of 
intra-pelvic disease as are of a chronic and obscure character, and 
which cannot be cured by the. ordinary means. 

In the wide range of cases in which my services have been re- 
quired, both in hospital and consulting practice, 
Practical results. I have f ound that my confidence in the value of 
the exploratory incision as a dernier resort has 
steadily increased. I have often made it, and so far as I know but 
one of my patients has died in consequence, and that was many 
years ago, before the days of antiseptics, or of proper haemostatics, 
and when we knew but very little of the prophylaxis which is now 
so indispensable a part of peritoneal surgery. In six of my cases, 
however, in which an ovariotomy would not otherwise have been 
attempted, it certainly was the means of saving life. AYith few 
exceptions, and when made by one who has had experience in this 
kind of work, whose hands are clean and who takes the proper 
precautions, it certainly is a safer and a much more satisfactory 
test of the real condition of aif airs in doubtful cases than is the 
resort to tapping. When a woman is dying from an obscure ab- 
dominal disease, the exploratory incision is not only admissible 
but it is sometimes a necessary procedure. 

Barring his opposition to careful antisepsis, the list of precau- 
tions proposed by Dr. R. S. Sutton,J are the best that I have seen. 
They include : 

1. Perfect cleanliness of the patient's abdomen. 

2. Perfect cleanliness on the part of the operator. 

3. Perfect cleanliness of the instruments. 

4. The patient must be thoroughly anaesthetized. 

5. Make a small abdominal incision, and secure every bleeding 
point before opening the peritoneum. 

6. Carefully open the peritoneum, pass two fingers through into 
the abdominal cavity and search for information. If you fail to 

*The Hahnemannian Monthly, for August, 1883. 

$The American Medical Association Journal, for January, 1887. 



954 THE DISEASES OF WOMEN. 

obtain the desired information, enlarge the abdominal wound in 
an upward direction, and search again. 

7. Make a careful peritoneal toilet. If necessary pour in clean, 
warm water, and sponge it all out. Close the wound by passing 
the sutures over a flat sponge laid beneath the wound. 

8. Never use carbolic acid or the sublimate solution; it is use- 
less and dangerous, unless it is merely used for the purpose of 
cleaning the operator's hands. 

9. Only the operator is to put his hand into the abdominal 
cavity. 

10. In tying the sutures, dry the lips of the wound with iodoform 
gauze. 

"Such are the precautions to be taken in making an exploratory 
incision, which if carried out will never be followed by any bad 
results." 

II. TAPPING.-OVAMOCENTESIS. 

I shall speak of tapping as a means of diagnosis, for "as a means 

of cure, tapping can never be supposed for a 

is not a curative moment to succeed in the case of distinctly mul- 

resource. _ ... 

tilocular cysts. This is admitted on all hands. 
The frequent tapping of such a tumor by a large trocar belongs to 
a past age, and is a cruel proceeding when done, as it yet too fre- 
quently is, by a practitioner who simply acknowledges thereby his 
inability to remove it and his unwillingness to ask any one else to 
do so." (Thorbum). 

Even in the parovarian cysts which yield the spring-water fluid, 
the tradition that they seldom or never refill after the first tapping 
and are therefore cured by it, is no longer tenable. And besides, 
as Pean* has shown, not only do these broad ligament cysts some- 
times contain a very different kind of fluid, but some of the sacs 
in a multilocular, and even in a malignant tumor of the ovary 
proper may be filled with this same clear, transparent, crystal-like, 
colorless water. So that tapping must not be too confidently de- 
pended upon either to settle the diagnosis or to result in the cure 
of a unilocular cyst of any kind whatever. 

The method of exploratory tapping has been greatly simplified 
by the use of the aspirator instead of the old- 
Mode of operating, fashioned dome-trocar. For, although the needle 
of the aspirator is of smaller size, and one might 
therefore suppose that the thicker ovarian fluids would not 
pass through it, they will usually be forced to do so by reason 

*Lecons de Clinique Chirurgicale, tome IV, 1886, page 1181. 



EXPLORATIVE METHODS OF DIAGNOSIS. 955 

of the vacuum that is created in the instrument. Even where the 
fluid is too thick to run freely we may get a few drops of it, which 
will be sufficient for our purpose. The bladder should first be 
emptied. The aspirator-trocar should be perfectly clean, and so 
also should the surface of the abdomen through which it is to be 
introduced. Selecting a spot along the mesian line of the abdo- 
men, which is high enough to avoid the fundus of the empty blad- 
der, and low enough to take advantage of gravity in emptying the 
cyst, or cysts, that portion of the integument is touched with a 
little strong carbolic acid. This has the effect to render the sur- 
face asceptic and the wound insensible, or nearly so. 

The best position for the patient to assume is upon the back 
with the head and shoulders raised; or upon the side with the pro- 
jecting abdomen brought to the very edge of the bed or of the 
table upon which she lies. If the puncture is to be made through 
the vagina, or the rectum, Sims' position is the better one. The 
instrument (Fig. 43) should be clean and in the best order. 

Having anointed the needle and exhaused the bottle of atmos- 
pheric air, you are ready to proceed without anaesthesia. When 
the point of the needle has pierced the skin the stop-cock should 
be turned so that the moment the needle has reached a layer or 
collection of fluid it will begin to flow toward and into the cham- 
ber that has been attached for its reception. If the quantity of 
the cyst-fluid is large, and the bottle needs to be emptied, care 
must be taken to prevent the admission of air into the abdomen. 
Do not forget that the sarcomatous cyst-wall is usually very thick, 
and that you may sometimes have need to thrust the needle almost, 
or quite its whole length before reaching the fluid. In exceptional 
cases the abdominal walls are so laden with fat that the contained 
tumor lies very deeply. In one of my ovariotomies, although the 
growth weighed twenty-nine pounds, I had to cut through four 
inches of fat and integument before coming down upon the peri- 
tone am. The woman made a slow recovery, but the cicatrix has 
not been very strong* 

With careful practice you may learn to use the needle-trocar in 
such a way as to do the least possible harm, and to derive the 
greatest amount of information. In the case of an old tumor 
especially, and whenever there is reason to fear that the growth is 
malignant, the withdrawal of the instrument requires the greatest 

*The Clinique, Vol. II, Dec. 1881, page 413. 



956 THE DISEASES OF WOMEN. 

caution. Remove it slowly, meanwhile pinching the integument 
between the thumb and index of the left hand, so as to secure the 
contraction of the tissues and the exclusion of air. Then cover the 
orifice with a bit of adhesive plaster, or of antiseptic gauze, pin a 
binder snugly around the body, and send the patient to bed for at 
least two days. 

It is not well to decide too hastily as to the significance of the 

fluid that has been drawn. It may be bloody 
The fluid drawn. from intra-cystic haemorrhage, or because you 

have accidentally punctured a small vessel on 
the interior of the cyst-wall, or because you have tapped a fibro- 
cyst of the uterus; or opalescent, if it has come from a parovarian 
cyst, or from one of the smaller cysts in a multilocular growth of 
the ovary. If it contains one or more hairs, it has originated in a 
dermoid cyst; and if it coagulates on standing, it is probably ascitic. 
I have already spoken (See Lecture LY. ) of the clinical value, or 
rather the lack of value, of the microscopical examination of these 
fluids. It is not to be depended upon as a diagnostic resource. 
The sticky, syrupy, adhesive quality of the true ovarian fluid is 
worth more to us in a suspected case, than the detection of any of 
its histological or its chemical elements. 

The form of the abdomen after the evacuation of the cyst, or of 

the compartment containing the fluid, especially 
The form of the abdo- if ^ j s a large one, is worthy of note. The scaph- 

men after tapping. > . . 

oid belly which was believed by Atlee to be 
diagnostic of a broad ligament cyst, when it had been emptied, is 
also, in exceptional cases, a sign of encysted peritoneal dropsy. 
But, if the clear, spring- water fluid has been drawn in considera- 
ble quantity, and the abdomen is afterwards concave, and palpa- 
tion fails to detect any trace of the thin, collapsed cyst, it will be 
pretty safe to conclude that the growth is parovarian. 

In a case of ascites complicating an abdominal tumor we may 
sometimes draw off the peritoneal accumulation in order to 
remove an obstacle to a thorough examination. This also will 
change the form of the abdomen, and give it a certain diagnostic 
value. The same is true of tapping the parent cyst in compound 
and malignant tumors. In this way the change in the form of the 
tumor that is left behind may signify a great deal more than either 
the quantity or the quality of the fluid that has been taken. More- 
over while it relieves suffering, the removal of the contained fluid 



EXPLORATIVE METHODS OF DIAGNOSIS. 957 

facilitates whatever subsequent manipulation is necessary. This 
point was illustrated in my last lecture, (see Fig. 174). It is not 
safe, or prudent, however, to make these subsequent examinations 
until after the lapse of some days, when all risk of injury to the 
organs, or of exciting inflammation of the peritoneum especially, 
shall have passed away. 

Whatever objections may be urged against tapping as an imper- 
fect and even a dangerous diagnostic expedient, 
Tapping as a palliative, it is permissib]e with proper precautions as a 
palliative measure in pregnancy, or bronchitis, 
or chronic renal disease, in anasarca, chronic cardiac or heptic dis- 
orders, in violent neuralgic pains from abdominal pressure and 
in acute peritonitis whenever they complicate ascites or any form 
of ovarian dropsy. Especially is this the case if for any reason it 
is not possible or prudent to make the exploratory incision, or the 
radical operation for the removal of the tumor immediately. 

In a very remarkable case of this kind one of our alumni, Dr. 
O. B. Blackman, of Dixon, 111., saved a woman 
case. whose life was despaired of and who had been 

given up to die with a violent attack of acute per- 
itonitis conjoined with ovarian dropsy, by tapping and removing 
thirty-two pounds of ovarian fluid. In a few months the parent 
sac refilled slowly, and she developed a suppurative fever with 
chills, hectic and emaciation. I then removed the tumor, the 
largest sac of which was nearly full of pus, and she made an excel- 
lent recovery. The growth weighed twelve pounds.* I have no 
doubt that she would have died of the peritonitis if the distention 
of the inflamed membrane had not been relieved by the puncture. 
Simple as it is, old as it is, and often as it is made by the gen- 
eral practitioner, the operation of tapping through 
ex T SiFent s a dangerous the abdominal wall is not devoid of danger. In 
the old days, when a dirty trocar and canula were 
often employed and antisepsis was unknown, the mortality from 
tapping was greater than it now is from the capital operation of 
ovariotomy! The table of first tappings arranged by Kiwisch 

*The following note was appended to the published history of this case: Upon opening this 
tumor the next day, at the hospital clinic, it was found to contain, besides the fluid that was 
left from the tapping during the operation, at least a quart of cheesy, stringy, decomposed pus. 
The 6ac was then inverted and the inner surface of the lesion, at its fundus, exposed. The class 
witnessed that, for the space of five inches across the top of the tumor, and two inches in its 
depth, the_ internal surfaces of the sac had been firmly and inseparably united by adhesive 
inflammation, which must have followed the first tapping, and which had prevented its refill- 
ing to the same extent as before. This tuck had really taken in four inches of the circumfer- 
ence of the cyst-wall. (The Clinique, Vol. Ill, page 142.) 



058 THE DISEASES OF WOMEN. 

gives a ratio of 17 per cent, of fatal cases; and Pean says* most 
expressively: 

"We can not forget that it was three cases of speedy death after 
the tapping of ovarian cysts in 1863, which caused us to resolve to 
make our lirst ovariotomy; nor that we have often known those 
who had been tapped by our confreres, to die within twenty-four 
hours, and just when they were disposed to have us operate for 
their relief. In March, 1884, this accident happened three times 
in one week. When, therefore, our patients are very much enfee- 
bled by previous disease, peritonitis, or affections of the heart or 
of the brain, it is better not to delay the radical operation by use- 
less tapping." 

That a lack of care in making so simple an operation as para- 
centesis of the abdomen may put a woman in peril even where it 
does not take her life, and that it may seriously complicate a sub- 
sequent ovariotomy is shown by the following case which came 
under my own experience : 

Case. — Mrs. K., of this city, aged fifty-four, the mother of six 
children, first noticed an abdominal enlargement five years ago. It 
has increased rapidly within the past four years. Two months 
and a-half ago she was tapped at a surgeon's office without any 
word of caution as to the risks of the operation; without the appli- 
cation of a binder, or any form of abdominal support; and she 
afterwards was permitted to go home as if nothing had happened. 
The shock and exposure made her very ill, and brought on an 
attack of peritonitis, which kept her in bed for three weeks, and 
nearly cost her life. She had never had any previous illness. 

January 31, 1882, three months later, with the assistance of Drs. 
A. K. Crawford, C. S. Penfield and B. L. Reynolds, I removed the 
tumor. Its weight was twenty-six pounds; the fluid was of the 
chocolate variety; and the growth was composed of four endogen- 
ous cysts. The large outer sac was adherent through every inch 
of its surface, on all sides, to the parietes of the abdomen in front, 
to the mesentery at its fundus, and to the intestines behind. These 
adhesions were the evident result of the recent attack of plastic 
peritonitis, which had been caused by the inexcusable and unchris- 
tian treatment of the poor woman. The pedicle was broad, thin 
and twisted upon itself. She reacted well and recovered without 
a single bad symptom. 

The sources of danger from exploratory tapping are various. 
There is a possibility that the puncture of the 
f rom sources of danger cyst-wall may develop into a rapture, with extra- 
vasation of its contents and a fatal collapse. In 
old cases in which the coats of the sac have become very thin 

*0p. cibat., Vol. IV, page 1179. 






EXPLORATIVE METHODS OF DIAGNOSIS. 959 

because of distention, or from the corrosive action of the contained 
fluid, this result is very likely to follow. The escape of a very 
small quantity of the noxious fluid when the needle or trocar is 
withdrawn, may cause an attack of septic peritonitis. I once tap- 
ped an old cyst with a hypodermic needle for the purpose of get- 
ting a sample of the contained fluid. In five minutes after the 
needle was withdrawn my patient was in a state of collapse, and 
two hours or more had passed before I became fully satisfied that 
she would recover from the shock. 

A serious objection to tapping in case of an intra-papillomatous 
cyst of the ovary is that the possible escape of some of the cancer 
cells may cause an extension of the disease to the surface of the 
peritoneum when otherwise it would have been limited to the 
interior of the sac, and therefore removable by ovariotomy. The 
risk of haemorrhage from puncture of one of the large veins that 
often lie upon the surface of the cyst is greatest in malignant 
cases; and the possibility of auto-infection from a consequent 
deterioration of the fluid where repeated tapping is practised 
should always be borne in mind. Uterine tumors, whether solid 
or cystic, or composite, are intolerant of the trocar. We should 
never tap one cyst through another, nor should we forget that in 
emptying a suppurating cyst by aspiration, the needle will take 
away only the liquid portion of the contained pus. 

Repeated tapping certainly increases the risks after ovariotomy, 

by the possible development of plastic peritoni- 
afterSvariotom 1 ! 6 risks tis> as in the case just cited; by draining away 

the patient's strength and lowering her vitality; 
by vitiating the contained fluid, and thus increasing the risk of a 
slow and insidious absorption and of sepsis that may exist before 
the ovariotomy is made ; and by the possible extension of an intra- 
cystic cancer to the tissues and organs that lie outside of the tumor. 



LECTUBE LIX. 



OVARIOTOMY. 

An early operation is best; suitable cases for; indications for; do. for an immediate operation; 
contra-indications for; qualifying do; preparatory treatment; asepsis and antiseptics; 
proper place, day and season for the operation; surgical cleanliness of room, instruments, 
etc.; the anaesthetic, assistants and necessary instruments; the patient's position and the 
incision; the arrest of haemorrhage; opening the peritoneum; an essential precaution; 
emptying the cyst; the adhesions; enucleation in dangerous do; haemorrhage from do; 
management of the pedicle; the clamp, the ligature, and the actual cautery; objections to 
the clamp and to the extra-peritoneal method; the peritoneal toilet; hot-water flushing for 
shock; drainage; the deep, continuous and superficial sutures; the special do. for a retained 
cyst; the first dressing of the wound; the do. for the drainage tube; putting the patient 
to bed. 

The frequency and the flippancy with which ovariotomy is 
referred to of late in some of our medical journals may have 
caused you to look upon it as an operation that is adapted to a 
wide range of cases, and one in which the best results are almost 
certain to follow its performance. The glamour that is thrown 
over this subject by the remarkable success of a few noted 
specialists may have tempted you to suppose it an easy matter to 
make such a reputation, if only you can find the patients, and 
they will consent that you shall operate. 

, The truth is that the relative popularity and safety of ovari- 
otomy since Dr. McDowell first made it in Kentucky, in December, 
1809, is due to such a persistent experimentation, training and 
drill iii everything that belongs to it, as has never been bestowed 
upon any other surgical operation. As a direct, although a some- 
what tardy result, instead of being rejected as hazardous, unwar- 
rantable and murderous, as it once was, ovariotomy is now made 
as successfully as any other capital operation. Indirectly its 
benefits are incalculable, for it has opened up the whole domain 
of abdominal surgery. Until it was practised, the peritoneal 
cavity and all that it contains was as inaccessible surgically as 
the chambers of the heart. But now there is not an organ that 
is covered with the peritoneum which can not if necessary be 
safely reached by the knife of the skillful gynaecologist; nor a 
scrap of tissue within its ample folds that is out of the range of 
his vision. 

960 



OVARIOTOMY. 961 

The following reasons will be a sufficient answer for those who 
would postpone this operation: 

1. We should not wait until the patient's general health has 

become impaired, or in other words, the prin- 
An early operation is c ipl e of such delay is a departure from that 
generally followed in the case of other diseases 
treated surgically. 

2. The presence of the tumor is the cause of structural disease 
in other organs. 

3. Ovarian tumors are liable to a variety of accidents, such as 
rupture, either from injury or spontaneously, and twisting of the 
pedicle, to morbid processes, such as inflammation, atheromatous 
degeneration of the blood-vessels, which with fatty change in the 
walls of the cysts leads to haemorrhages into their interior, etc. 

4. The existence of adhesions, of degenerative changes in, and 
rupture, etc., of the tumor, greatly interferes with the success of. 
the operation. 

5. On the contrary, the earlier and simpler the operation, the 
greater is the chance of recovery.* 

Among those who suffer from some form of ovarian tumor 
there is a choice of subjects for this operation. The proportion 
of favorable cases has greatly increased since I 
otom y ablecasesforovari " began to operate, about fifteen years ago. At 
that time the majority of these patients had 
either been repeatedly tapped, or neglected until it was almost or 
quite too late to operate upon them with a reasonable hope of 
success. But now such old and unpromising cases are compara- 
tively rare, for they have been weeded out; and the professional 
habit to defer the radical operation as long as possible has 
changed into a plea for early ovariotomy. Moreover, the tech- 
nique of the operation has been so perfected that certain cases 
which were once unsuitable are so no longer. 

This change of circumstances has had the double effect to 
increase the ratio of recoveries from ovariotomy, and to diminish 
the number of conditions that constitute a bar to the operation. 

The more rapidly the cysts fill or refill after the tapping, the 
stronger the reason for an early operation. A decided failure of 
the general health, with loss of appetite, insom- 
ovariotSSy ns for eady n ^ a ' gastric and intestinal irritation, dropsy of 
the face, hands, or feet; dyspnoea, inability to 
lie down, or to walk because of the size of the tumor, with evident 
"signs that she can not live unless she is relieved, are so many 
pressing indications for ovariotomy. 

The demand for an immediate operation becomes imperative in 

*A Plea for Early Ovariotomy, by G. Granville Bantock, M. D., Etc., London, 1881. 



962 THE DISEASES OF WOMEN. 

case of a rupture of an ovarian cyst, with a discharge of its con- 
tents into the cavity of the abdomen. The pos- 
opCTSio f n. ranimmediate sibility that such an accident may happen where 
there is great distention, or where the parent 
cyst is an old one, suggests that we should always be ready for 
such an emergency, and that the operation should not be deferred. 
In July, 1884, a fine, healthy-looking woman came to me from 
Michigan to be relieved of a large ovarian tumor. The journey 
was by boat and she was sea-sick. After landing I made her two 
visits, when her vomiting ceased, the abdominal pain and soreness 
had yielded, and she was up and about her room. Two days later 
on turning in bed after an afternoon nap, she had a sharp, cutting 
pain, felt something give way, sank into collapse and, before I 
could reach her bedside half an hour later, was dead. 

Hemorrhage into the cyst, with or without torsion of the pedicle, 
furnishes what might be styled a dramatic indication for immedi- 
ate ovariotomy. The following case in which I successfully 
removed a hemorrhagic cyst, with a solid tumor weighing thirty- 
eight pounds, illustrates the importance of operating promptly. 
Dr. Frederic Stevens, our former house-surgeon, had the care of 
it after the operation, and has kindly furnished the following 
notes : 

A multilociriar ovarian cyst iveighing thirty-eigjii pounds — 
abundant haemorrhage into the parent cyst — ovariotomy — recovery. 

Case. — Mrs. , aged forty-seven, is the mother of four children. 

Fourteen years ago she had left-sided ovaritis. Since then she 
has been generally well, with the exception of some functional liver 
trouble. 

"In December, 1885, she noticed a slight general enlargement 
of the abdomen. This increased slowly until March, 1886, when 
she began enlarging very rapidly. About May 1 the growth of 
the tumor ceased, and from this time until the month of August, 
she decreased four inches in size. The diagnosis of cystic disease 
of the ovary was made by Dr. Lucllam in May, and an immediate 
operation advised by him. During August the tumor again grew 
rapidly, causing dyspnoea, constipation and general malaise. The 
emaciation was marked and rapid. On September 15, Dr. Ludlam 
was again consulted, and the date of operation was set for Septem- 
ber 25. In the night of September 19 she began failing rapidly, 
becoming blanched and extremely weak and nervous. 

"She called me for relief from fai?rfcing spells, to which she was 
unaccustomed, and I found it necessary to remain with her most 
of the night. She had marked signs of collapse, her pulse was 
thready and feeble; she felt certain that for some cause the tumor 
was growing, and, brave as she had always been, was now im- 
pressed with the conviction that she was about to die. I sum- 



OVARIOTOMY. 963 

moned Prof. Bailey, who was near at hand, and with the aid of 
stimulants we got her through the night. 

"On account of the urgency of the symptoms the operation was 
made the next morning, September 20, 1886. There were present 
to assist Prof. Ludlam, Drs. E. S.Bailey, Frederic Stevens and B. 
L. Reynolds. The patient was extremely weak, on the border of 
collapse, and the pulse filiform, 120, and scarcely perceptible. 
The tumor had evidently increased and changed in form since it 
was examined five days before. 

"The tumor included four cysts, the largest of which, on being 
tapped, at first discharged a fluid of a very dark port wine color. 
The fluid soon looked and smelt like fresh blood, and was evidently 
hemorrhagic. The tumor was removed, the pedicle secured, the 
toilet of the peritoneum carefully made, the wound closed, and 
the patient put to bed. 

"The cysts and their contents weighed thirty-eight pounds; but 
when the fluid which had been taken from the large sac was 
poured from the tub in which it had been collected, it contained 
half a pailful of bright and large blood-clots. 

"The patient reacted promptly and made a rapid recovery, sitting 
in her chair at the end of two weeks. On the- tenth day the 
sutures were removed and the wound was entirely healed. After 
the first evening, when it was 104, the pulse ranged from 80 to 86, 
and the temperature, which was 100 \° with the first reaction, did 
not afterwards exceed 99° and a fraction." « 

At my hospital clinic on Wednesday, September 22, the parent 
cyst which had contained the blood was opened before the class, 
and the site and peculiarities of the ruptured vessel were clearly 
demonstrated. The profile of the abdomen before the operation 
is faithfully shown in Plate III. But for our prompt attention 
that woman could not have lived more than a very few hours. 

Unless in chronic cases of renal disease, with blood, pus, or 
tube-casts in the urine, the presence of albumin in that fluid 
would not interfere with the operation, except- 
ovariotom^ 10 ^ 10118 for ing to make us careful in the choice of the anas- 
thetic. Serious complications, whether acute 
or chronic, on the side of the heart, the lungs, the liver or of the 
nervous system, might render the subject unfit for the operation. 
And so also of old scrofulous or tuberculous affections of the 
mesenteric glands, with diarrhoea, hectic, emaciation and ascites. 
Diabetes with absence of the tendon reflex is regarded by a promi- 
nent authority as a positive contra- indication. Chronic bronchitis 
and pulmonary catarrh are serious obstacles, especially if the 
patient has passed the climacterie. 

I have already spoken of the frequent involvement of the right 



964 



THE DISEASES OF WOMEN. 



heart, especially in the case of cystic tumors within the abdomen. 
(Lecture LY., page 915). Old cases of cardiac degeneration,, 
and not of mere functional or even of valvular disorder, are much 
to be dreaded as complicating ovarian dropsy. A case of this 
kind to which I was called by my friend Dr. T. C. Duncan, of this 
city, will serve both as an illustration and as a warning. The 
history thereof was kindly furnished by Dr. Duncan. 

Cysto -carcinoma of the ovaries — double ovariotomy — death from 
heart-failure. — Case. Mrs. W. came into my hands some twenty 
years ago at the death of Dr. Lyman Kendall. She was subject 
to attacks of palpitation, and when very severe there was a loss of 
consciousness. Her friends often thought that she was dying. 
Dr. K. had often resuscitated her with spigelia. She was a tall, 
spare brunette; ambitious, active and hopeful, but subject to severe 
metorrhagia. She carried a sensitive spine, and at one time 
barely escaped meningitis. The spinal tenderness increased 
during severe and prolonged activity. The appetite was always 
poor, the tongue red and pointed and the stomach sensitive to the 
touch. Accute attacks of gastritis usually attended the times of 
extra overwork. As she approached the climacteric, the flow was 
almost constant, only a weeks interval occuring; but it was only 
while the stomach rebelled that medical help was solicited. I 
urged systematic treatment, especially after I had obtained con- 
sent to a local examination and had found an hypertrophied, 
prolapsed uterus. During last winter, for a severe attack of uterine 
distress, I was finally summoned. I found the hypertrophied uterus 
completely ante-verted, a high grade of inflammation present, and 
an undefined pelvic tumor. The uterus was reposited and the 
inflammation allayed. In May dropsical symptoms began to 
develop, notwithstanding the uterine flow was again almost 
constant. This was checked and she was able to get about. But 
in July all of the symptoms returned with renewed vigor. The 
most excruciating pain was located in the head and neck. 

"The heart attacks returned, but under the use of medicines this 
phase of the case rapidly and steadily improved. The neck and 
head symptoms also improved, and all went on well, except that 
she was very weak, had but little appetite, and the dropsy grew 
apace. The pelvic distress and fullness, however, was ever present. 

"September 4, the distension became so great that I tapped her 
and drew off ten quarts of a pale liquid. Through the now flabby 
abdomen was outlined a hard, nodular tumor. At this juncture 
Prof. Ludlam saw the case and advised abdominal section, with a 
view to the possible removal of the tumor, as soon as she could get 
an appetite and recruit sufficiently. He was of the opinion that 
the tumor was of a malignant variety, and that, if possible, the 
sooner it was removed the better. After the tapping the appetite 
became good and she improved in strength and spirits. The heart 



OVARIOTOMY. 965 

seemed greatly improved. But in two weeks the abdomen again 
became enormously distended, and this was accompanied by severe 
pains on the right side. Again I tapped her and drew off as much 
highly albuminous liquid as before. 

"Again the appetite returned, and she insisted that an operation 
should be made before the abdomen refilled. One tumor was found 
to fill near the whole right side of the abdomen, and another was 
detected in the left side. But a few days elapsed before the ab- 
dominal distension was pressing. All felt that in this condition 
she had but a very short time to live. An operation offered a hope, 
and it was determined upon with the gravest fears that her feeble 
system might not withstand the shock. 

"September 30, 1886, Prof. Lucllam opened the abdomen and 
brought to light a very large condensed multilocular mass, parts 
of which were already gangrenous. There were no adhesions, and 
this mass, which involved the right ovary, was quickly removed 
and the pedicle secured. A smaller mass, including the left ovary 
and lying chiefly in the Douglas pouch, was turned out and secured 
in the same way. Not two tablespoon sful of blood were lost by 
the operation, which was made under sulphuric ether carefully 
given. The intestines and the omentum showed a high degree of 
peritoneal inflammation. None of the cysts were ruptured or 
tapped, nor did any of them burst, and consequently not a drop of 
the vitiated fluid escaped into the abdominal cavity. 

"When the second pedicle had been secured and the operator 
was about to close the wound, the patient suddenly, and without 
the least warning, ceased to breathe, and no expedient, even to the 
use of nitro-glycerine, was of any avail in restoring her." 

In that case the operation was made with a full appreciation 
and understanding, by the patient and by the family, of the immi- 
nent risks incurred. Every precaution was taken to prevent what 
has been styled an "unexpected collapse," and to bring the woman 
through the operation safely. I am satisfied that her sad and 
sudden death (which is the first and the only one that has ever 
happened to me while operating), was due to heart-failure and to 
nothing else. An autopsy was not allowed.* 

The more frequently the woman has been tapped, or tampered 
with by electricity, blisters, etc., the greater the risk of the oper- 
ation. We would not often be justified in removing an ovarian 
cyst that contained pus, if it has already found vent through an 

*If the reader is disposed to question the propriety of my having undertaken so serious an 
operation in this forlorn case, 1 beg leave to answer in the manly and memorable words of 
Prof. Goodell: "I have always contended that, for a surgeon to decline to operate on any case 
of ovarian tumor because it is not a promising one, is virtually the same thing as if he had 
operated on the case and had lost it._ Acting on this principle, no matter how desperate the 
condition of the woman, I have not in a single instance, refused to give the sufferer her only 
chance for life. * * * * * This regard for the woman and disregard for my statistics, has 
swelled my list of fatal cases, and has given me one death on the operating table; but, on the 
other hand, it has enabled me to restore to life, two women who had been abandoned bv other 
surgeons." {The American Journal of Obstetrics, etc., vol. XV, page 364). 



966 THE DISEASES OF WOMEN. 

opening into the bladder or the intestine. Nor would it be safe 
or expedient, in most cases, to operate before the tumor was large 
enough to distend and develop the abdominal parietes somewhat. 

A few years ago, extensive adhesions of the tumor were thought 
to contra-indicate the operation, and they did very often cause it 
to be relinquished. But now we know that, excepting in case of 
pelvic and hepatic adhesions, their danger has been greatly exag- 
gerated. The same is true of a co-existing pregnancy. Yov 
should not perform ovariotomy during the prevalence of any 
severe epidemic, such as cerebro-spinal meningitis, diphtheria, 
puerperal fever, or erysipelas. 

The question of the safety and propriety of ovariotomy will 
turn upon these points. But, while we ought not to run too great 
a risk in resorting to it in extreme cases, we 
tiS? s alifying indica " should remember that it does offer a means 
of cure where everything else must fail. In so 
far as the heart and lung complications are concerned, my own 
practice has been to make the tolerance of the anaesthetic the test 
of its expediency. If the pulse and respiration are calmed and 
the ether has a pleasant effect, I go forward. 

You may find it advisable to cut down upon a cyst that has 
only partially refilled after tapping, because it 
is evident that the patiant can not recover if it 
is not taken away immediately. I made the operation in a case of 
this kind upon a patient of my friend, Dr. C. W. Crary, at Lake 
City, Minn., on the first day of June, 1878. Her baby was only 
three months old. She really had not gotten through with her 
puerperality. After her delivery, the tumor had grown very 
rapidly, and a week before my arrival the doctor had very properly 
tapped it. This afforded the greatest relief, but as soon as it 
began to refill, her strength gave way, and it became evident that 
she must sink from the drain. I cut down upon the flabby sac 
through a resonant abdomen, and, despite the worst possible 
enteric and mesenteric adhesions, we had the satisfaction of saving 
the poor woman's life. 

The dangers of the operation, and the contingencies that beset 
the first month after it has been made, should always be explained 
to the patient and to her family beforehand. For, like the doctor, 
she must enter upon it intelligently, or the result may be disastrous. 

For a week previous to the operation, unless you are forced to 

remove the tumor at once in order to save her life, the patient 

should have a nourishing but easily digested 

Preparatory treatment. -, . . TJ . , . • , -, -i , , -■ • ■ -i 

diet. It she is emaciated and the skin is dry 
and husky, let her take a warm bath the day before the operation. 



OVAEIOTOMY. 967 

The bowels should be freed of any accumulation, and the morning 
and evening pulse and temperature taken and recorded for some 
days beforehand. It is very important that her mind should be 
tranquil and that her neighbors should not annoy her, and indeed 
that, as a rule, they should not know what is about to be done for 
her relief. Her urine should be carefully tested for albumin. 
On the morning of the operation she should abstain from all solid 
food and take only a light breakfast, otherwise the risk of vomit- 
ing while under the anaesthetic will be very much increased. 
Four or five hours before the operation she may have a cup of 
strong beef-tea. ' 

The peritoneum is so susceptible that we must be very careful 
not to expose it in an unsanitary atmosphere. This remark 
applies to the making of laparotomy for any 
fJpScs iB and anti " purpose whatever; and it explains the necessity 
of extraordinary precautions in abdominal, as 
distinguished from general surgery. In an amputation of the 
leg, for example, the wound is readily accessible and any unfavor- 
able conditions that surround the patient can be overcome by 
antiseptic and.hygenic measures that are available at any time — 
before, during and after the operation. But in ovariotomy the 
sensitive peritoneum is exposed during the operation, after which 
the wound is closed and corrective measures, excepting in rare 
cases, are thenceforth excluded. It follows that the proper time 
for aseptic precautions, in this and all kindred operations, is 
while the abdomen is open. 

To meet this indication, and to bring the full force of antiseptic 
treatment to bear as a prophylactic, the carbolic spray and the use 
of strong germicidal solutions was resorted to a few years ago, as 
in ordinary surgery. This was done to render the parts thor- 
oughly aseptic. But it soon became evident to the careful gyne- 
cologist, that the peritoneum is quite as intolerant of certain anti- 
septics, as it is of whatever might float in a vitiated atmosphere, 
and so occasion septic mischief. Keith observed that his ovari- 
otomy patients had hematuria when carbolic acid had been used; 
and, indeed, that he had it himself whenever he operated under 
the spray. And Billroth and others have reported fatal results 
from this intra-peritoneal asepsis with carbolic acid, the mercuric 
chlorides, iodoform, etc. The consequence is that the practice of 
throwing the spray directly into the abdomen has been very 
generally relinquished, and so also has the use of strong antiseptic 
solutions in ovariotomy. 

With the reaction against the early abuse of peritoneal asepsis 
gynecologists are now divided into two camps: those who still 



968 THE DISEASES OF WOMEN. 

resort to it in a more or less modified form, and those who, reject- 
ing it altogether, prefer to depend upon absolute cleanliness as 
the best safe-guard against all septic and pysemic mischief. Most 
operators of experience belong to the former class, and even when 
they do not use antiseptics during 'the operation, insist upon all 
sorts of pre-operative precautions and of post-operative dressings. 
However, Keith, Bantock, Tait, and their followers discard these 
measures altogether, and contend that they are not only useless 
but injurious. 

My own idea is that the middle course is the safer one. Indeed 
my practice has been to combine the two methods, for I have 
failed to see how they could conflict. Surely there is nothing 
inconsistent between cleanliness and careful antisepsis, and, under 
the varying conditions in which we are called upon to operate, it 
would not be best to depend upon either of them exclusively. 

In deciding whether an ovariotomy should be made at the 
patient's home or in an hospital, certain practical considerations 

must be weighed. The advantages of a country 
theopCTat P ion Placefor nom e, if it is in a healthful locality, are that 

you are certain to have a good supply of fresh 
air and of sunlight, with wholesome, nourishing food, and an ab- 
sence of bad odors, dirt and noise. When the family is in good 
circumstances, and all the sanitary requisites can be supplied, 
these very desirable conditions will more than counterbalance the 
best and most scientific resources of the hospital. Moreover, 
there are certain very sensitive women upon whom the moral effect 
of going into a hospital for such a purpose might be very damag- 
ing, and consequently we must sometimes regard their very posi- 
tive preference. But the disadvantages of having to depend upon 
an indifferent or inexperienced nurse, and of having one's patient 
at arm's length after the operation, when the contingencies are so 
numerous, furnish a strong argument in favor of having it done 
at a first-class, special hospital, whenever the patient can afford, 
or will consent to go there. 

Now that we can control and regulate the physical surround- 
ings of the patient, it is no longer necessary to limit the season 

for making an ovariotomy to the early summer, 
seas h on day and the or to tlie autumn months. With the proper 

precautions it may be safely done at any season, 
excepting in the very hot weather, and even that is permissible in 
cases of emergency. I have operated, and successfully too, with 
a range of temperature of from 90° above, to 30° below zero; 
but the greatest care was taken to counteract the possible ill effect 
of these extremes of heat and cold. The day set for the oper- 



OVARIOTOMY. 969 

ation should be clear and bright, with a wind from any quarter 
excepting the north-east. As in other gynecological operations 
it is better, but not essential, that this should follow instead of 
immediately precede the monthly flow. 

In the outfit for this operation, no instrument is more important 
than the thermometer — I mean the thermometer which is designed 

to regulate the temperature of the patient's 
rooS? perature ° f the apartment, both during and after the removal 

of the tumor. While the operation is in pro- 
gress, my practice is to keep the temperature at 75° F., and not 
allow it to fall below 70° day or night, for five or six days after- 
wards. This matter should be insisted upon not only because of 
the risk of chill and of the onset of inflammation from vicissi- 
tudes of temperature, but also because it has been found that 
tetanus sometimes arises from this cause. 

The room in which the operation is to be made should be 
thoroughly scrubbed, whitewashed, cleared of its carpets and rugs, 

disinfected and afterwards opened to the fresh 

Surgical cleanliness of . .-,-.. .. . , , .\ ,. -, ., 

the room, instruments, air. The operating table, the linen, and the 
towels, should also be thoroughly cleaned, and 
disinfected either by burning sulphur or by the carbolic, or the 
mercurial spray. The usual method is to leave these articles in 
the vapor while the room is tightly closed through the night 
preceding the operation. The instruments should be surgically 
clean. Each one should be thoroughly cleansed with hot water 
and soap; then wiped off with absorbent cotton saturated in 
glycerine and carbolic acid. After this they may be laid in the 
sun, or upon a hot stove for an hour or two; or better still, passed 
through the flame of a spirit-lamp before they are used. They 
should not be mixed with other instruments. During the opera- 
tion I usually have them immersed in Listerine. The sponges 
should be fine, new, and absolutely clean and aseptic. 

Some years ago it was my custom always to give the patient 
a dose of whiskey just before she took the anaesthetic. The object 
was to lessen the quantity of ether that would be necessary, to 
stimulate the circulation, and to promote rest and quiet after- 
wards. But I learned from observation that, especially in those 
who were unaccustomed to alcoholic stimulants, it; sometimes 
increased the vomiting and also made it necessary to give them 
more instead of less of the anaesthetic. Others prefer to resort 
to morphine for a similar purpose. My friend Helmuth recom- 
mends that some twenty minutes before the time set for the 
operation an hypodermic of ten minims of a solution of sulphate 
of morphine eight grains, and the sulphate of atropia half a grain 



970 THE DISEASES OF WOMEN. 

to the ounce of water, should be administered. "This solution 
quiets the patient, stimulates the heart's action, and, very often, 
after the operation, secures for her a refreshing nap for an hour 
or two." 

Most operators are careful to know that the bladder has been 
emptied just before the patient is placed upon the table; but 
Keith advises to leave it in a distended state, in order that its 
outline and its attachments can be more readily made out, and 
to protect it from injury. If the catheter must be used during 
the operation, it should be passed by an assistant. 

The operation. — The last thing to be done before she is placed 

in position is to have the abdomen thoroughly cleansed with 

" ' warm soap and water, after which it may be 

Trip jmspstriptic *^ 

dried and coated over with such a solution of 
iodoform and ether as you have seen Prof. Shears inject into ab- 
scesses for their radical cure. Hegar's idea that it is likely to 
excite vomiting if the patient is allowed to take the anaesthetic 
before being placed upon the table should always be borne in 
mind. Unless there is albuminuria with or without tube-casts, or 
some valid sign of urinary disorder, or unless we have an old 
patient with bronchial catarrh, (broncorrhcea) sulphuric ether is 
undoubtedly the best anaesthetic. In that case we must use chloro- 
form ; but chloroform is not suited if the heart is crippled as it 
is likely to be from fatty degeneration of the right ventricle in 
old abdominal tumors. So we must proceed cautiously and be 
prepared for emergencies. For the ill effects of ether, hypodermics 
of rye whiskey, or ammonia; and for those of chloroform, injections 
of ether, or inhalations of the nitrite of amyl, with lowering the 
head and raising the body toward the ceiling are the best ex- 
pedients. 

If, as sometimes happens, the ether is not sufficient to produce 
the requisite insensibility we may give a few whiffs of chloroform 
with plenty of air, and very cautiously, until there is profound 
anaesthesia, and then resume the ether. Or it may be the best 
to substitute the Vienna mixture, which is composed of one part of 
alcohol, two parts of chloroform, and three parts of ether. Who- 
ever gives the anaesthetic should realize that, after the incision has 
been made through the integument, only enough ether is necessary 
to keep the patient quiet; that real narcotism is neither safe nor 
necessary ; and that, above all things, he must stop giving it so as 
to avoid collapse while a large cyst is being emptied, and also 
while the tumor is being delivered through the abdominal wound. 
When nausea occurs during etherization it may often be stopped 
by pushing the anaesthesia still further. 



OVAKIOTOMY. 971 

The ether is best given with a Clover's inhaler, such as is used 
in my clinic. I prefer it because much less ether is required, and 
the patient is brought directly under its influence without carrying 
her to the point of saturation before she becomes insensible. If 
this instrument is not available, or if chloroform is used, the old- 
fashioned paper or rubber cone will answer. 

While the patient is being anaesthetized in another room, the 

assistants should be instructed concerning their special duties. 

Their number should be limited to five at the 

The assistants. . e i ji r» j i ii; V • 

most; or whom the first should stand vis-a-vis 
with the operator, use the sponges and apply the haemostatic 
forceps. The second should give the anaesthetic, and not be 
concerned with anything else; the third should have charge of 
the instruments, be ready to thread the needles and to apply the 
necessary ligatures; the fourth will cleanse the sponges for the 
first assistant ; and the fifth, who is the nurse, supplies the hot 
water, the bandages and blankets, and prepares the room and the 
bed for the patient. Each and all of them must have taken a 
general bath, put on clean and disinfected clothing, scrubbed 
their hands and arms and especially their finger-nails, and washed 
them in an antiseptic solution. They must be absolutely free 
from all sources of infectious disease. I once lost a young and 
beautiful woman after an ovariotomy because one of the physicians 
who was present at the operation told me that he had not treated 
a case of contagious disease for a long time, when he was actually 
in charge of a patient with malignant scarlatina. The puerperal 
and eruptive fevers, diphtheria, small-pox, and bad cases of typhoid 
fever poison the doctor's clothing, and one who has been thus 
exposed, or who has very recently performed or assisted in an 
autopsy, should not be allowed in the room, or in the building, 
during an ovariotomy.* 

There is no need of making a parade of instruments sufficient 
to stock a cutler's shop. Two scalpels; a pair of straight and 
strong scissors; six pairs of plain haemostatic 
ment e s necessary instm " forceps (Fig. 176), and three ditto with gold- 
washed handles; a No. 7 or 8 steel sound; a 
Pe'an's trocar; two blunt tenaculae; two pedicle forceps; a Baker 
Brown's cautery clamp ; a Pacquelin, or some other form of cautery ; 

*"It is, unfortunately, a melancholy story that ever since surgery began, the most of the 
mischief was done by the surgeon himself. It was the willing and tender, though unclean 
hand, that carried the poison into the wounds. It is to this that Lister hasput a stop. With a 
proper antiseptic, an operator is now made to be clean in spite of himself, is compelled to have 
safe sponges, safe ligatures, clean instruments, and, above all, clean fingers. If one be careful 
enough— and few are careful enough— one may do all this as Mr. Tait does, with boiled water 
alone. Some such precautions are essential; beyond these, with ordinary care, we need not 
disturb ourselves much as to what is in the air."— Keith. A Contribution to the Surgical 
Treatment of Tumors of the Abdomen. Part I., pages 23-4. 



972 THE DISEASES OF WOMEN. 

Wilcox's ovariotomy forceps; the necessary needles; a number of 
aseptic sutures and ligatures of catgut, silkworm gut, silk and 
silver wire (No. 26) ; six fine surgeon's sponges, and one flat one; 
a small ecraseur; with carbolic acid, or the sublimate solution 
(1 — 2000) ; drain tubes, adhesive plaster, iodoform, some kind of 
antiseptic gauze, a square bit of fine rubber cloth, and two ounces 
of rye whiskey ; half a dozen soft towels, and hot and cold water 
at command include all that you will need, even in complicated 
cases. The instruments and sponges should be counted before- 
hand, and a list of them kept in order to be certain that none of 
them have been left within the abdomen when the wound is 
closed. 

The table should be brought before the window into a strong 

light, and the patient's hips raised to facilitate the gravitation of 

the intestines away from the lower abdomen, 

The patient's position. v i j.- ■ j x. x> • i • \e 

an expedient practised by Kecamier in his first 
vaginal hysterectomy, in 1829. Her under-clothing should be 
of flannel, covered with a cotton night-gown, with woolen stock- 
ings; and the limbs should be wrapped in a woolen blanket. Care 




Fig. 176. Pean's forceps. 

should be taken so to arrange the clothing as to prevent its being 
soiled, and to avoid the necessity of its being changed directly 
after the operation. If you use the Macintosh, after the English 
method, it will be necessary to have her arms and legs secured. 
It the tumor does not extend far into the lower pelvis, a large 
sponge may be placed in the posterior cul-de-sac, to keep the 
Douglas pouch inverted. 

I prefer to make the incision in the mesian line, just as you 
saw me do at our last clinic (October 17, 1887). At first it need 
not exceed four inches in length. A recent 
author says: "With regard to the actual 
incision, it must be remembered that there is no linea alba below 
the umbilicus. Unless the muscles are separated by distension, 
the knife will open one or the other rectus sheath. The abdomen 
should be opened by precise, clean cuts ; a director is an abom- 
ination, and the practice of deepening the wound with the fingers 
belongs to the surgery of past ages." (Treves.) 



OVARIOTOMY. 973 

The greatest care should be taken to stop the haemorrhage as 
you proceed. The hot sponges are haemostatic, but they should 

not be used in a rough way. Gentle pressure, 
haemorrhage. ° f the an( ^ no * a ru de mopping of the wound is best. 

We never put a ligature in this wound any 
more, but rely upon the artery forceps to control any active 
haemorrhage. Before a large vein is cut, two of these forceps 
may be so placed that the vessel can be severed between them. 
The more there is of venous oozing, and the lunger the time con- 
sumed in controlling the flow and cleansing the wound, the 
greater the probability of a multiple cyst, or of a malignant 
growth, with extensive adhesions, and with a depraved quality of 
the cyst-contents. 

Coming down upon the peritoneum it is caught up by a pair of 
forceps and nicked, after which the opening may be enlarged 

with the scalpel, or with the blunt-pointed 
toneum ing the peri scissors. By Atlee's test, which consists in 

passing the steel sound through the opening to 
observe if it glides beneath the umbilicus, we may not only decide 
the question of having gained access to the peritoneal cavity, 
but may also satisfy ourselves as to the existence, or the non- 
existence of anterior parietal adhesions. 

If the tumor is multilocular and a very large one, or if it has a 
large solid portion which is filled with condensed cysts, the 
original incision will need to be extended. This can best be done 
with the strong scissors, cutting between two fingers, which are 
placed as guides to prevent injury to the intestines, or the omentum. 
If the patient has an umbilical hernia, my practice is to cut directly 
through the ring, but if not, to go to the left of it. The edges 
of the enlarged wound should be everted, and the haemorrhage 
arrested immediately. 

An incision of medium length is better than either a very long 
or a very short one. The objection to the long incision is not on 

account of its subsequent healing, but chiefly 
incision ensth ° f the because of an unnecessary and dangerous expo- 
sure of the intestines. The objection to the 
very short incision is that you have less freedom in managing the 
adhesions, that multiple cysts are likely to be ruptured, and that 
the parts involved are more severely traumatised than if there 
was plenty of space in which to operate. 

Apart from the ordinary surgical precautions, the great point 
in ovariotomy is to keep the blood and all infective material out 

of the abdominal cavity. The greatest care is 

An essential precaution. ... .. , ,i , i , , 

requisite not to rupture the cysts, and not to 



974 



THE DISEASES OF WOMEN. 



suffer a drop of the contained fluid to overflow and to fall back 
again. This indication will not be filled if the parent sac is old 
and rotten, if the patient happens to vomit just at the wrong time, 
or if the trocar is allowed to slip out of the cyst-wall so that the 
nasty fluid may escape and deluge the parts. The possibility 
that it may happen in any case suggests the propriety of covering 
the edges of the wound and the intestines, if they are exposed, 
^with soft warm towels, or flannels, before the cyst is emptied. 




Fig. 177. Pean's trocar. 

The tumor should now be tapped and the fluid run off in^o a 

basin or bucket that is held by an assistant. The point of the 

trocar should be passed so as to avoid wounding" 

Emptying the cyst. ,, i xi j -j? -j p t 

the vessels that ramity upon its surface. I 
prefer Pean's ovariotomy trocar (Fig. 177), to that of Spencer 
Wells (Fig. 178), as being more convenient and less savage and 
harmful. So soon as the cyst begins to collapse, it should be 
seized and drawn towards the ceiling by a Wilcox forceps, which 




Fig. 178. Spencer Wells' trocar. 

I consider a very valuable instrument (Fig. 179). In lieu of 
this, I have for many years employed a Sims' polypus forceps, 
which answers a very good purpose. 

Before the technique of this operation had reached its present 
state of perfection, I was accustomed to stitch up the sac and to 
leave a considerable portion of the fluid within it, so as to facili- 
tate the management of the adhesions, and of the pedicle, to keep 
the intestines warm, and to preserve the form of the tumor mean- 
while. But that is unnecessary now; the only requisite precaution 
being to keep the wound made by the trocar from pouring its 
dregs into the abdomen. 



OVARIOTOMY. 975 

It is the practice of some operators to turn the patient upon 
her side, and then to make a free incision into ^ the cyst, so as to 
discharge its contents more quickly and rapidly. A better way 
is to use a Tait's cyst-trocar (Fig. 180), which is a curved tube 
and not a cutting instrument, and with which the partition walls 
of a polycyst can be broken down without introducing the hand 
into the sac. This large-sized trocar will empty a bucket of water 
in about a minute and a half. Whichever method is adopted, 
you should not forget to have the anaesthetic suspended while the 
evacuation is going on. The practice of rupturing the smaller 
cysts through the walls that separate them from the larger one is 
often, but not always safe or expedient. 




Fig. 179. Wilcox Forceps. 

If there are adhesions, and they are seldom absent in genuine 
ovarian dropsy, they should be managed very carefully. I first 
examine the anterior surface of the tumor, and 
separate them in front before disturbing those 
which are behind, below, or at the sides of the abdomen. Then, 
if the cyst, or cysts, can be drawn slowly and deliberately through 
the incision, the more distant adhesions will be disclosed, and 
can often be separated without putting the hand into the abdomen. 
Stringy, vascular, fibrous, and especially omental adhesions 
should be ligated twice with fine gut, or carbolized silk, and cut. 
between. It is sometimes necessary to include a mass of the 
omentum in a strong ligature in order to put a stop to the oozing 
at its torn edges; but in this case we should not forget that the 
arterial supply of the intestine might be readily cut off by the 
ligature. Or, being careful not to prick the vessels in the 
mesentery, we may darn up the torn edges with the continuous 
catgut suture. 

Enteric adhesions should be manipulated with the greatest 
care. By pressure with a hot sponge the gut is separated from 



976 



THE DISEASES OF WOMEN. 



the tumor (the stripping being always on the side of the tumor) 
and the intestine brought out upon the abdo- 
oJ adSon?. in danger " men where it is covered with a soft, warm, moist 
towel. If these, or any other adhesions can 
not be safely detached, the coats of the sac may be divided and 
so much of its peritoneal investment as corresponds with the 
extent of the adhesions left behind. In a terrible case, in which 
the tumor weighed eighty pounds, I resorted to this expedient 
and by the enucleation of nearly one-third of its surface averted 
death from haemorrhage.* My patient made a good recovery and 
was well eight years after. 

In a monocyst, if the wall of the sac is not too thin and tender, 
and if the adhesions extend over all, or nearly all of its surface, 
you may split its layers and enucleate the tumor and strip out 




Fig. 180. Tait's Cyst-trocar. 

its secreting membrane without disturbing the pedicle, or doing 
any serious damage. The hull will afterwards collapse and its 
surfaces adhere so as to dispose of the tumor. In October, 1873, 
I removed a thirty-pound accumulation of syrupy ovarian fluid in 
this way. The patient recovered, and twelve years after she had 
had no return of the tumor, f 

Sponge pressure, torsion of single vessels, forcipressure, liga- 
tion, the use of the Pacquelin cautery, and afterwards the filling 
and flushing of the abdomen with water at the 
temperature of 103° to 105° or even to 115° are 
the best means for arresting the haemorrhage 
from the torn adhesions. Wy lie's expedient of clamping the 
pedicle before the adhesions are disturbed may answer the same 

*The United States Medical Investigator, April, 1878. 
fT/ie U. S. Medical and Surgical Journal, vol. IX., p. 225. 



How to control 
haemorrhage from. 



the 



OVARIOTOMY. 977 

purpose in exceptional cases. Oozing from a large abdominal 
surface may be arrested by making a fold in the integument, 
doubling the raw surface upon itself, and transfixing by an acu- 
pressure needle, or by the cobbler's stitch passed from skin to 
skin, as recommended by Dr. Kimball. 

Experience has taught me that pelvic adhesions are the most 
difficult to manage, and that when they are extensive the tumor 
is almost always malignant. The possibility that adhesions may 
have formed low down in the connective tissue, about the pedicle, 
should make us very careful not to lift the tumor so high as to 
tear them at an inaccessible point, and so to induce death from 
concealed haemorrhage. Dr. Emmet reports a death from undue 
traction upon the pedicle. 

How to treat the pedicle has involved more experiment and 
controversy than any other step in the operation of ovariotomy. 
Having turned the tumor out of the abdomen, 
P edfck geiIlent ° f the and in the kindest and safest way disposed of 
the adhesions, you look for the stalk upon 
which it has grown, and through which its chief sustenance has 
been derived. It may be long or short, thick or thin, broad or 




Fig. 181. Spencer Wells' pedicle forceps. 

slender, single or double, and may or may not include the body 
of the uterus. When fully exposed it should be seized and com- 
pressed with a Spencer Wells' pedicle forceps or with the Baker 
Brown clamp-forceps. Having secured it, without including a 
bowel loop, the edges of the incision should be held together, 
and the lower angle of the wound covered all about the pedicle 
with warm towels or flannels. Then the tumor is cut away and 
the forceps remain astride the pedicle. The towels keep the blood 
and the fluids coming from the tumor from falling into the ab- 
domen, and are afterwards removed, and the parts sponged clean. 
Another method is first to compress the tissues of the pedicle 
with the forceps, then remove them and to pass the ligatures and 
tie them before the tumor is cut off. This plan is best suited for 
single cysts or small tumors, and also for securing the pedicle 
in oophorectomy. 



978 



THE DISEASES OF WOMEN. 



Now you must settle upon one of the two general methods of 
managing the stump: either it must be secured and held outside 

the abdomen, which is the extra-peritoneal 
methods^. general method; or it must be ligated, or cauterized, or 

both, and then dropped back into the abdomen, 
which is the intra-peritoyieal method. In the former case some 
kind of a clamp, such as Thomas's, (Fig. 182), or Spencer 




Fig. 182. Thomas' clamp for the pedicle. 

Wells' (Fig. 183), is placed above, or below the forceps, screwed 
T , down and the forceps removed. The pedicle 

is then brought forward and the instrument 
placed across the lower end of the incision. 

If, however, you determine upon dropping the pedicle into the 




Fig. 183. Spencer Wells' clamp for the pedicle. 

peritoneal cavity, as first practised by Dr. Nathan Smith, of Con- 
necticut, in 182 L, the course to be pursued is 
very different. By lifting the forceps or the 
attached tumor, the pedicle may be pierced between its vessels 
either by a Skene's needle, or by a straight one, at each end of 



The ligature. 



OVARIOTOMY. 979 

an aseptic silk ligature. If the pedicle is a narrow one, the 
Skene's needle will carry a loop that can be passed over the 
pedicle and secured in the form of the Staffordshire knot. {Fig. 
184.) Or, if you prefer, you may cut the loop, and tie one thread 
each way about the two halves of the pedicle. But you must not 
forget to cross these two ligatures, or they may separate the 
halves of the pedicle and slip off. (Fig. 185.) 

If the pedicle is a stout one it cannot be safely ligatured either 
en masse or in sections. It must be sewed with the cobbler's 
stitch and made very secure before the forceps are removed. And, 
when they are taken off, it is well to seize it with a pair of 
haemostatic forceps on each side, so that it will not be lost sight 
of until you are ready to close the abdomen ; for it may be neces- 
sary to put a separate ligature upon one or more bleeding vessels. 
The small forceps with gilt handles should be used for this 
purpose, and also for the application of sponges within the ab- 
domen, it being desirable to identify them and their special use. 
Meanwhile the opposite ovary should be carefully examined and, 
if it is found to be diseased, drawn to the light, clamped with the 



WIIMM 



cr 

Fig. 184. Tait's Staffordshire knot. Fig. 185. The unsafe method. 

forceps and excised in the same manner. This will constitute a 
double ovariotomy. All the ligatures should be cut short before 
the pedicle is dropped. 

Having tied the pedicle and trimmed off its superfluous tissue 
the cautery may be applied to the stump until it is thoroughly 
charred. Dr. Keith, who divides the pedicle 
with the cautery and trusts to it without the 
ligature, applies it so as to heat the clamp-forceps and cook the 
part which is included in that instrument. In either case the 
eschar prevents all septic oozing and keeps the stump from be- 
coming attached to the neighboring organs. For the last three 
years my own practice has been to use both the ligature and the 
cautery as a double precaution, and as a consequence the results 
obtained have been much better than they were before. 

I am quite confident that by the revival of the Baker Brown 

method of treating the pedicle with the cautery 

clamp and to°the extra! and without the clamp, the elder Keith and 

peritoneal method. Lawson Tait have put the profession and oar 




980 THE DISEASES OF WOMEN. 

common humanity under a lasting obligation. For the clamp is 
indeed "a coarse, unsurgical instrument," which, through the 
establishment of septic channels from the sloughing stump directly 
into the peritoneal cavity, has slain many a poor woman who but 
for it would most certainly have recovered. And what is true of 
the use of the clamp applies also to the whole extra-peritoneal 
method in ovariotomy. Not only does the use of the clamp render 
the seeping of the septic debris into the abdomen almost certain ; 
it also prevents the careful and thorough drainage from the 
Douglas pouch which is often so very necessary during the first 
few days. 

The cleansing of the peritoneum is a matter of the greatest 

moment. Not only must the abdomen be emptied of clots and 

debris, and all active haemorrhage stopped, but 

The peritoneal toilet. . , . . , , , , *? , ; , , 

the parts must be made absolutely clean, and 
the Douglas pouch especially be left as dry as a pocket. For 
slovenly surgery can be tolerated anywhere else better than within 
the abdomen and the pelvis. The more extensive the adhesions, 
and the older the tumor, the greater the danger of subsequent 
oozing and sepsis. If a rotten sac has been torn, or if from any 
other cause a portion of the fluid has escaped into the peritoneal 
cavity, extraordinary pains must be taken to clean it out 
thoroughly. 

There are two methods by which the abdomen may be cleansed 
after the delivery of an ovarian tumor and the necessary ligation 
of its pedicle. One of these is by careful sponging, and the other 
is by washing and flushing it. No matter how soft the sponges, 
or how carefully they are used, they are so likely to do damage, 
especially if the peritoneum or the omentum are diseased, that 
the best operators have learned how to get along without them 
whenever it is possible. The most efficient and harmless sub- 
stitute for them is the use of water at a temperature of 100°, or 
more if the hemorrhagic tendency is pronounced. This may be 
run into the abdomen, while the flaccid parietes are being held 
up by an assistant, through a Tait's trocar used as a syphon; by 
a fountain syringe; or it may be poured in slowly by the pitcher- 
full until it overflows. Meanwhile the hand or the fingers may 
so manipulate and rinse the intestines and the other organs 
about the pelvic brim that they shall be washed quite clean. 
Whichever way the water is introduced its use should be con- 
tinued until the overflow is clear and not discolored. 

I have had frequent occasion to confirm the value of Tait's 
remark that the best means for dissolving the thicker and more 
sticky ovarian fluids (including the colloid material which is so 



OVARIOTOMY. 981 

apt to escape from its cyst-wall when it has one, and which can- 
not be removed by sponging) is to pour on it a slow and steady 
stream of warm water. For this reason the cleansing should as 
far as possible be done with water, and not by sponging. And 
in removing the water the patient may be cautiously turned upon 
her side, or the tube by which it was introduced may be used as 
a syphon to carry it off again. When it is all out the parts may 
be examined by an electric lamp or by a hand-mirror, and the 
retro-uterine pouch carefully mopped with a soft warm sponge, 
or napkin, or with a bit of iodoform gauze. 

Aprojios of this intra-abdominal bath, in making the toilet of 
the peritoneum I warn you not to forget the invaluable suggestion 
of one of Dr. Sims' pupils concerning the 
6h?c°k twaterflurihingfor efficacy of the hot water flushing in case of 
shock and great exhaustion.* To fill the ab- 
domen in this way is the most rapid and available means of 
stimulating the necessary reaction. It possesses the double ad- 
vantage of being in a line with the necessary local treatment, and 
does not interfere with the use of other restoratives. 

The indications for drainage are identical with those which 
require that the abdomen should be thoroughly cleansed, with 
the added risk of hemorrhagic oozing and 
serous accumulation after the wound is closed. 
The older the patient the greater the necessity for drainage, be- 
cause the ability of the peritoneum to absorb and to remove 
effused fluids is sometimes very much lessened in this class of 
cases. Moreover, the vitality of women who have passed their 
fiftieth year and have developed an ovarian cachexia is often so 
low that they are easy victims of septic infection. 

The attempt to do away with the necessity for drainage by render- 
ing the peritoneal cavity thoroughly aseptic has been generally 
abandoned, and for the practical reason that it could not be made 
so and kept so without very great risk of poisoning the patient, 
no matter what antiseptic was used. The result has been that 
the old methods of drainage, which often did more harm than 
good, have been so improved that they may now be depended upon 
to keep the wound and all that it includes both clean and sweet. 
And since these conditions will avert sepsis and suppurative fever 
we must see to it that in all serious cases they are faithfully 
supplied. 

Having tested the various methods of drainage I believe that 
the one which you saw applied in my clinic a few days ago is the 

*Prof. W. Gill Wylie, in the Medical Record for March, 1887. 



982 THE DISEASES OF WOMEN. 

best. If you will take a Keith's glass tube (Fig. 186), or a 
Tait's do. (Fig. 187) and insert it at the lower angle of the 
wound its perforated extremity may be easily passed over and 
behind the uterus into the Douglas pouch. Then, having care- 
fully dried the wound with a warm sponge, or with a bit of iodo- 
form gauze, the tube should be held in place with its open end 
upwards until you have passed the sutures and are ready to tie or 
to twist them. Or, if you prefer to do so, you may pass the 
sutures first, and afterwards put the tube in position, before the 




Fig. 186. Keith's glass tube. 

wound is closed. The perforated tube that is closed at its lower 
end, like a test-tube, is preferable. It will need to be left in situ 
for from two to eight or nine days, or so long as the discharge 
obtained from it continues to be colored. 

After counting the forceps and sponges, to be certain that none 

are left behind, a large, clean, flat sponge should be placed within 

the wound and over the intestines, to keep them 

The sutures. . . . , . -, .. -. x -, , 

warm, to prevent their being injured, and to 
keep all blood from the needle punctures from dropping into the 
abdomen. The sutures may be of prepared silk, the silk- worm 




Fig. 187. Tait's glass tube. 

gut or of silver. The first of these are so readily adjusted, so se- 
cure, and so thoroughly aseptic that I confess to a growing fond- 
ness for them in closing the wound in all cases of laparotomy. 

Whether they are passed from within or from without, the 
deep sutures, which are not more than one-eighth of an inch 
apart, should include a pretty wide strip of 
peritoneum along the margin of the wound, the 
intervening muscular layer and the integument. This precaution 
will secure the immediate union and closure of the peritoneum, 
and so prevent the admission of infectious material from without. 
It will also keep the intestines from protruding in the form of a 
hernia, which once was so frequent a sequel of ovariotomy 



Concerning the number and nearness of the sutures Dr. Keith 



says 



OVARIOTOMY. 



983 



"In the early days of ovariotomy, when the wound was closed 
by harelip pins put in at intervals of an inch, a hernial protrusion 
was the rule; but since I have put in a great number of sutures, 
and I think I put in twice as many as any one else, and take in the 
whole deep tissues of the wall, I have seldom had to see a patient 
on account of airy discomfort arising from the wound. There is 
no greater mistake than to include only the skin and peritoneum. 
This is Sir Spencer Wells' method. It saves trouble at the time 
perhaps, but in a month or two the patient suffers. It is said that 
the cicatrix comes to this in the end in all cases. It does not; with 
a properly united wound, with a sufficient number of deep sutures 
taking in all the tissues, no hernia ought to happen. I am not 
sure but the wound is firmer when the middle line is avoided, and 
the sheath of one of the recti muscles is opened throughout." 

It is a good plan to insert all the deep sutures before tying 
any of them, the ends being held on either side within the jaws 




Fig. 188. An emptied cyst, or sac, to be stitched to the abdominal wound. 

of the lock-forceps. This ensures the exact adjustment of the 
edges of the wound, favors the removal of the underlying sponge 
after they have all been passed, and enables one to decide upon 
the necessity of stitching the peritoneum separately. I like 
Thiriar's idea of first bringing the edges of 
the peritoneum together with the continuous 
^atgut suture, and afterwards tying the deeper 
ones. This method is adapted to the closure of a long incision, 
especially if it had extended through the umbilical ring, and is 
'. , designed to dispose of a hernia, and also to 

The superficial sutures. °. , ■ i ,-, -n j_. . i 1 i 

one m which the walls or the abdomen are 



The continuous peri 
toneal do. 



984 THE DISEASES OF WOMEN. 

unusually thick. If any superficial sutures are required they 
should be of catgut, in order that the dressings need not be dis- 
turbed for their early removal. 

In very exceptional cases the tumor cannot be removed and the 
only alternative is to empty its contents, stitch the edges of the 

cyst into the abdominal wound, and drain its 
aS£nS C c? 1 s r turcfor cavity. The sutures will in that case need to 

be passed in the same manner as for the radi- 
cal cure of pelvic abscess, or for the ultimate disposition of the 
sac in extra-uterine pregnancy. (Fig- 188). 

The wound being closed, the abdomen is quickly cleansed and 
dried, and the line of the incision sprinkled with iodoform. Then 
a compress of iodoform-, mercurial, or carbolic gauze two or three 

inches wide, is laid along the wound, and adhe- 
wound firstdressing ° fthe slve straps are put across it, so as to keep it in 

place, and to afford the requisite support in case 
of vomiting. Over this is a good thick layer of absorbent cotton, 
or of cotton batting, which is secured by a binder around the 
body. Before the binder is adjusted, however, if the drainage 

tube is being used, pledgets of the same gauze 
drai'nag^tub^ ° f the are placed all around at the lower angle of the 

wound. Then we take a square bit of thin 
rubber-cloth, as big as a lady's pocket handkerchief, cut a little 
hole in the center of it and put it down over the free end of the 
tube, after the fashion of the dentist's rubber-dam. This is care- 
fully folded, one corner afc a time, over the open mouth of the 
tube, and not only serves to keep the air from the abdominal 
cavity, but also furnishes a ready means of knowing what is 
going on inside. 

The soiled clothing having been removed, the bed should be 
open and ready, and the patient carefully carried to it from the 

table. Her body should not be doubled in the 
^Putting the patient to middle? nor should the head be raised. Warm 

blankets should be placed about her legs and 
bottles of hot water (but not too hot) at her feet, and elsewhere, 
to arouse the circulation and stimulate a reaction. But, the 
operation being finished, we shall speak of the after-treatment 
and the results in ovariotomy at our next lecture. 



LECTUBE LX. 

THE AFTER TREATMENT IN OVARIOTOMY. 

The importance of; quiet and absence of visitors; the temperature of the room; shock and re- 
action; pain and restlessness; the.pulse and the clinical thermometer; thirst and appropriate 
drinks; the diet; flatulence and tympanites; Dr Jenks' expedient for; case; nausea and 
vomiting; do. with sepsis and peritonitis; from gastro-intestinal ulceration; case ; the urine; 
the condition of the bowels; salines in peritoneal complications; the care of the drainage 
tube; dressing the wound; re-opening the wound for secondary hoemorrhage; for the intra- 
peritoneal bath; case; for secondary drainage; the removal of the sutures; the convales- 
cence and the first getting up; case; contingent affections; bronchitis and pneumonia; 
cases; parotitis; phlebitis, phlegmasia, thrombosis; acute mania; case; bed-sores in old 
patients. The results in Ovariotomy ; the causes of the comparatively low death rate of late 
years. 

The after-treatment in ovariotomy, as in all cases of peritoneal 
surgery, is of the utmost importance. In everything that per- 
tains to the care of these patients you should 
bear in mind the homely old maxim quoted by 
one of my nurses a day or two ago: "It is better to be sure than 
sorry.'' All the little details must be looked after most care- 
fully, and the beginnings of morbid mischief averted or arrested 
without delay. Any preconceived notions of luck or fortune as 
connected with the recovery of ordinary surgical cases; any 
prejudice in favor of the all-powerful influence of antiseptic pre- 
cautions, or confidence in the patient's general good health, or 
her pluck to "pull her through," no matter what happens, should 
not be allowed to interfere with the most cautious and careful 
management of the case in hand. For, even in the simplest and 
most promising case, the technique of the nursing for the first 
fortnight, or longer, may be quite as important as that of the 
operation itself. 

To begin with, as soon as the patient .s put to bed, if the opera- 
tion has been made in the same room, the table, instruments, and 
everything that is not needed should be taken 
of Q viStor| nd absence away, and as quietly • as possible. From the 
very outset she will need the same general 
treatment as if she had passed through a perilous childbirth. No 
noise, or stir, or flurry, or whispering should be allowed; and as 
much as possible the patient should be left alone with the nurse. 
If she sleeps quietly and breathes well, let her alone. If she 
flounders, she must not be oermitted to turn uoon either side. 



986 THE DISEASES OF WOMEN. 

If the weather is cold, or the nights are cool and damp, or if 
it becomes rainy, the temperature of the room should be care- 
fully regulated. A thermometer should be kept 
the h r e oom mperature ° f f° r this P ur pose and frequently consulted. For 
the first four days the temperature should not 
be allowed to fall, day or night, below 70°, nor should it exceed 
75°. If the weather is warm, the windows must be kept open. 
Fresh air and plenty of it is indispensable in all cases. 

If the condition of the pulse and of the skin show that she is 

reacting from the shock, she may not need anything but to be 

kept warm in bed, and to have a good supply of 

Shock and reaction, » > • -i-> , • r? i 1 n ,-, "7 ■ 

iresn air. i3ut it she has been greatly exhaust- 
ed, and the pulse flags and the skin is cool, give her a hypoder- 
mic injection of rye whiskey every hour, or oftener. This will 
antidote the depressing effect of the ether, and tide her over the 
difficulty. In very weak cases I have sometimes ordered this 
prescription to be repeated every hour or two during the first 
night, or until food could be safely taken. In the case of an 
Irish woman living in a miserable shanty on Quincy street, and 
who had one of the worst ovarian tumors that I ever removed, 
the parent-sac burst and its vile contents were extravasated into 
the abdomen. This was before we knew anything of flushing the 
peritoneum or of drainage, and while we were still crucifying our 
patients with the clamp. She was extremely weak, did not react 
well, could take no food, and but for the whiskey, which she took 
by the mouth after the first twelve hours, must certainly have died. 

Inhalations of spirits of ammonia or of camphor, or, in case 
chloroform has been administered, a whiff now and then of the 
nitrate of amyl, or a hypodermic of sulphuric ether, may be of 
good service to stimulate and to resuscitate the patient. 

In some cases where the pain and restlessness are pronounced, 

it is a serious question whether an opiate of any kind should be 

given. Of late years I very much prefer not to 

Pain and restlessness. °-, , - . -, . , . / » j ' • • 

allow it unJess the necessity tor rest is impera- 
tive, when a hypodermic of morphia with atropine is best. My 
friend Helmuth extols the internal use of hypericum for this pur- 
pose ; but my reliance has generally been upon frequent doses of 
aconite 3, and arnica 3, in alternation. 

The pulse is more trustworthy than it is in a lying-in-woman. 

But, like either of the probable signs of pregnancy, it will not 

answer to depend upon it exclusively. We want 

something with which to compare it, and, so to 

speak, to balance its record. And that something is the clinical 

thermometer. 



THE AFTER TREATMENT IN OVARIOTOMY. 987 

By the careful and intelligent use of this instrument we obtain 
a more accurate idea of our patient's condition than we can pos- 
sibly have in any other way. When a septic 
mom e ete?! mical ther ~ contingency is sprung, it sounds the first alarm. 
And not only does it notify us in season, but it 
often tells us whether or not we are doing the right thing. The 
information which it gives concerning the patient's condition will 
be as absolute and exact as possible. It will not be biased by the 
caprice, the fears, or even the sufferings of the patient, by the 
story of the nurse, nor by the hazy intuitions of the doctor. 

The temperature may be taken by the mouth, or by the vagina. 
If the respiration is normal, place the bulb of the instrument be- 
neath the tongue, and then have the mouth 

Manner of using it. , -. T ., ,, £ . , , 

closed. .Leave it there tor two minutes by your 
watch, and then make a note of the temperature upon a sheet of 
paper that is kept for the purpose. For the first day or two the 
observations may be taken every six hours, after which they 
should be repeated every morning and evening, as in our puer- 
peral ward. The pulse should be taken at the same time and 
carefully recorded. 

Keep these figures, so that you can consult them; for, not 
unfrequently it is quite as important to look oyer the past record 

of a case, as it is to forecast its future. The 

Value of the record. -i- • i -\ • ± j. j ■ • • i 

clinical hints, as to diagnosis, prognosis, prophy- 
laxis, and treatment, that you will derive from this study are the 
counterpart of those which are proper to the disorders of lying- 
in, and you can do no better than to translate and apply them in 
a similar way. 

Almost the first complaint is of thirst; and if you have not laid 
down the rule very plainly and peremptorily, the nurse or some 

kind friend will be tempted to give your patient 
ate^rfnS 01 appropri " something to drink. Sometimes the craving for 

water is almost irresistible, but it is so likely to 
excite vomiting that it is not safe to allow it within the first 
twelve hours. Meanwhile, the mouth and lips may be moistened 
with a cold, wet rag, or a pellet of ice may be allowed to dissolve 
in the mouth occasionally. When the effects of the anaesthetic are 
gone we usually begin with hot, instead of cold drinks. Hot 
water, hot tea, or better still, hot milk and water may at first be 
taken in very small quantities, and not too often, to test its toler- 
ance, and afterward more freely. If the stomach remains 
irritable, the carbonated soda or champagne may be given. A 
pint of tepid water as a rectal enema will sometimes allay a tor- 
menting thirst. For the first forty-eight hours the remedies 



THE DISEASES OE WOMEN. 

should be given in powders or pellets, else the water which holds 
them in solution may readily excite vomiting. 

Of all the articles of diet that are available for these cases, 

especially during the first week, the best is good cow's milk ; but, 

for fear of inducing colic, it should be diluted 

The diet. 

and taken very warm. Where it has disagreed 
with the patient heretofore, it may be peptonized. A light gruel 
of oatmeal is always permissible, and so also is genuine home- 
made beef tea. Barley water with cream may be kindly received 
by a delicate stomach, which will afterward tolerate good mutton 
broth, oyster soup, or something more substantial. 

The best rule that I know of in the matter of feeding these 
patients is to wait until flatus has first been passed by the bowels 
before giving them anything hearty. For this purpose my habit 
is to instruct the patient to tell the nurse when this has happened, 
so that we may know how to proceed. By this simple sign we 
can be assured that the proper peristaltic action of the aliment- 
ary tract has been resumed, and that neither emesis nor flatulence 
are so likely to follow the taking of food. And, although we do 
not in these modern times expect the patient always to drag 
through a tedious suppurative process before she recovers, it still 
is best to feed and to fortify her as soon as it can be done with 
safety. 

One of the most annoying and rebellious symptoms is flatu- 
lency. It may be due to the dyspeptic habit; to a superficial 
Matuience and tympan- ulceration of the gastric or the alimentary 
ites - mucous membrane that is septic in character 

and chargeable to auto-infection in old cases of ovarian dropsy 
and uterine tumors; or to the intestines having been chilled, or 
traumatized, or perhaps twisted when they were being reposited 
before the wound was closed. For the dyspeptic flatulence, if 
the patient is intelligent, it is a good rule to allow her to take 
whatever has relieved this symptom in her former experience. 
If she has observed that a drink of hot water would do it, let her 
have it again; or soda or camphor, or peppermint, or whiskey, or 
what-not ; but you must try the effect of these things carefully, 
for if this symptom persists it may develop into obstinate 
vomiting. 

If from the previous history of the case you have reason to 

believe that there is gastric ulceration, argentum nitricum 6, 

arsenicum alb., phosphorus, or nitric acid may 

Nausea and vomiting. . , , , L , \ an i - -re j_i • i 

possibly have a good elxect. It there is much 
distention give chamomilla, colocynthis, belladonna, or nux vomica, 



THE AFTER TREATMENT IN OVARIOTOMY. 989 

and change the position of the patient. While this symptom con- 
tinues all food and drinks should be given by rectal enemata, 
and nothing except the dry medicine taken by the mouth. 

These means are also suited to overcome any slight intestinal 

obstruction, with or without tympanites, especially should the 

patient be turned toward one side or the other 

for tympanites from in- slowly and gradually, and propped in that 

testinal obstruction. •. • tt 1 1 i i 1 i u 

position. Her head and shoulders may be 
raised, and her position so changed as to favor the escape of gas 
and to add very much to her comfort. In the worst of these 
cases, where life is imperiled by the occlusion of the bowel and 
the accumulation of gas, recourse may be had to another kind of 
postural treatment that was first practised by Dr. E. W. Jenks, 
of Detroit, in 1878. He published a remarkable case, in which, 
at the ninth day after an ovariotomy, "the patient was seized 
with a severe attack of vomiting, which caused the clamp to be 
torn loose, the lowest suture to be also torn out, and the lower 
angle of the abdominal wound to yawn, through which gap the 
serum from the abdominal cavity exuded for two days." The 
usual remedies relieved the tympanites, and there was no "doubt 
of her ultimate recovery until the twenty-third day after the 
operation, when the tympanites again became troublesome, and 
she complained of her inability to pass any flatus by the rectum, 
and of pain in the region of the pedicle." All other means 
having failed, a long rectal tube was passed as far as the sigmoid 
flexure of the colon, where it encountered the seat of an obstruc- 
tion which a copious injection could not overcome. The symp- 
toms became more distressing in character, hiccough set in, the 
countenance was pinched and anxious, the vomiting was more 
frequent, and she grew rapidly feeble. 

"She seemed so near moribund from exhaustion that she was 
entirely indifferent as to what was being done for her. With the 
aid of my colleague, Prof. Andrews, and one of my assistants, I 
took the patient from her bed, and gradually inverted her; there 
was no effect manifest from partial inversion, but when we got 
her in the position of complete inversion, really standing upon 
her head, there was, to our gratification and the manifest relief of 
the suffering woman, a rush from the anus of the pent up intes- 
tinal gas, coming out with a force more remarkable than anything 
of the kind I ever before witnessed. The patient, as she began to 
experience relief, instead of being passive in our hands, complained 
in no mild terms of the unkind and ungentlemanly treatment she 
was receiving. From this time there was no further trouble; if 
the gas seemed to be accumulating or was not readily expelled, 
raising her hips, gentle kneading, or turning her from side to side 



990 THE DISEASES OF WOMEN. 

would cause it to be expelled. The patient encountered no more 
difficulties, and made an excellent recovery.* 

If there is a form of volvulus which this expedient will not 
relieve, the wound should be re-opened, and the twist of the gut 
about its mesenteric axis, or upon itself, or whatever lesion may 
obstruct the passage of flatus, carefully sought for and relieved. 
This is a last resort, but it should not be deferred too long. 

"The trinity of peritonitis, tympanites, and vomiting are the 

furies of abdominal surgery. When they have taken firm hold 

of a case, we may make up our minds for a 

Nausea and vomiting. ^ . i ' -i i» " n i , i mi 

tierce struggle before they can be ousted. The 
longer they abide, the more difficult are they to be got rid of ; 
therefore, we ought to be prepared at every point to meet them 
with the most trustworthy weapons and the most approved tac- 
tics." — (Greig Smith.) 

That this triple source of mischief and of danger has been in 
a measure obviated by the adoption of the intra-peritoneal method 
of treating the pedicle, and by careful drainage, there can be no 
doubt. The dragging of the stump through the wound and its 
fixation by the clamp was often a cause of vomiting that nothing 
would relieve; and the sepsis which came from the accumulation 
of blood and serum in the Douglas pouch and behind the bladder 
often developed a dilatation of the stomach and the regurgitation 
of the ingesta which might be palliated but could not be cured. 
Now we know that these causes are avoidable, and that, with 
some rare exceptions, we need not be discouraged if the nausea 
and vomiting do not promptly yield to the appropriate treatment. 

It has been observed that vomiting is more apt to occur in 
cases in which numerous ligatures have been applied to the ad- 
hesions during the operation ; but now that the haemorrhage is 
arrested by sponge-pressure, by prolonged pressure with a soft 
cotton cloth, as advised by Dr. Kimball, or by a stream of very 
warm water, this cause of emesis is also avoidable. In most 
cases, however, the tendency to eructations and to an intolerance 
of food and drinks bears a certain relation to the flatulency, and 
the treatment already given for that symptom is also suited to 
this. A sip of hot water occasionally will sometimes settle a 
turbulent stomach just as a slight shower calms the stormy sea; 
but it will not always do it. And so also will a few doses of 
ipecac, or of mercurius, especially if the tongue is pasty, or of 
other remedies under their usual indications. In some cases 
relief is obtained, for a time at least, by having the patient drink 
a large quantity of warm water, so as to completely empty the 

* American Journal of Obstetrics, the Diseases of Women, etc., Vol. XI, page 513. 



THE AFTER TREATMENT IN OVARIOTOMY. 991 

stomach. In others the same effect has been induced by rinsing 
the organ with the stomach tube, or gavage. 

But the serious question is whether a persistent vomiting, or 
one that occurs after the first few days or a week, is not due to 
some form of sepsis, or to peritonitis, or to both 
toStis. sepsi8andperi " these conditions. If it is, the most active 
measures will be necessary. We must look to 
the drainage of the abdomen, or we must resort to intra-peritoneal 
injections, and even, if necessary, reopen the wound to get rid of 
the local cause of the trouble. Under the old regime, nature 
cured some of these cases by bursting open the incision and giv- 
ing vent to the contained fluid, after which the patient recovered 
in spite of the doctor. 

If there is an accompanying diarrhoea it is evidently critical, 
showing that a form of intestinal drainage has been established 
which may prove salutary. Long before Tait had prescribed 
saline cathartics as prophylactic o£ peritonitis following abdominal 
operations, some of us had observed this fact; but it was for him 
to insist that we may induce free watery stools to abort this form 
of inflammation. If you are satisfied that your patient either has, 
or threatens to have peritonitis, you may remember this hint and 
act accordingly. 

In old cases it sometimes happens that, through a depraved 
cachexia, and the possible absorption of some 
int^ti^uicSSi. 111 " 1 <rf the cyst-contents, an irrepressible vomiting 
with dilatation of the stomach will depend upon 
ulceration of its lining membrane. The following is a case in 
point, the lesion being confirmed by an autopsy. The patient 
was brought to me by Prof. C. W. Eaton, of the University of 
Iowa. 

Case — Mrs. , of Des Moines, was forty-eight years old, mar- 
ried, and the mother of four children, the youngest being four years 
old. All of her labors had been difficult. She was a woman of 
intellectual tastes and of nervous temperament. She first observed 
an enlargement in the epigastric region about one year ago, and the 
most unpleasant symptoms attending it were referred to the 
stomach. The paroxysms of pain and indigestion which were fol- 
lowed by vomiting, soon became so frequent that she was forced 
to diet herself very strictly to prevent them. She had also been 
subject to haemorrhoids and to inveterate constipation, and at times 
the urine had been very copious. 

The abdominal distention finally became so great that her phy- 
sician thought it advisable to relieve it by tapping, which he did 
about two months ago, when seven and one-half quarts of reddish 
b>rown fluid were withdrawn. In six weeks, she was again tapped, 



992 THE DISEASES OF WOMEN. 

and eight quarts of a pale amber-colored fluid were taken. The 
third tapping was performed about ten days previous to the opera- 
ation, and Rye and a half quarts of a dirty brown fluid were removed. 
At each tapping the fluid was highly albuminous. 

Her menstruation had been normal in every respect, and she had 
not reached the climacteric, although there were signs of its near 
approach. 

I made the operation in the hospital, November 6, 1880, with the 
assistance of Drs. Shears, Crawford, Eaton, Keynolds and Paul. 
The patient bore the anaesthetic very well, and the operation lasted 
one hour and a quarter. There was a good deal of venous 
haemorrhage from the incision, and the parietal and lateral adhes- 
ions covered the whole right and part of the left side of the tumor. 
This tumor consisted of three lobes, the largest of which was 
crowded into the epigastric region. It weighed twenty-five pounds 
and proved to be of the endogenous variety, each of the lobes con- 
taining a great many cysts of various sizes. 

The patient reacted well, and gave the best possible promise of 
recovery. She was under the constant supervision of Drs. Shears 
and Eaton. With the exception of pain in the gastric region as 
from gas, and a great deal of nausea, which began on the second 
day, and continued with eructations, she was quite comfortable 
until the morning of the third day, when she vomited badly. She 
then became very thirsty, weak and tremulous, with heat of the 
head and of the hands, dryness and redness of the tongue, gastric 
tympanitis, and scanty urination. In the evening the abdomen 
was washed out, but the fluid that was withdrawn was clear and 
unchanged. On the fourth day the vomiting was almost incessant 
with absolute intolerance of food. Rectal enemata had the effect, 
apparently, to increase the vomiting. The epigastric reigon became 
enormously distended, and the urine less free. Remedies had no 
effect whatever on the nausea and vomiting, and she died at eight 
A. m. of the fifth day. 

The post-mortem was made with the assistance of Drs. Crawford 
and Paul, and in the presence of Profs. Hall and Leavitt, and of 
Class No. 8, from my sub-clinic. An incision was made parallel 
to that made in the operation, and two inches to the right of it. 
By careful examination, the wound was seen to have healed very 
kindly and completely, both internally and externally. The site 
of the extensive parietal adhesions was plainly observable, but 
there were no signs of peritonitis, either there, or anywhere within 
the abdomen or pelvis. There was no effusion of lymph upon the 
intestines, no blood, or bloody serum, or clots, anywhere, nor was 
there a drop of pus to be found within the peritoneum, along the 
incision, or about the pedicle or the clamp. In all respects the 
process of union and of repair had proceeded without any obstacle 
or complication whatever. 

The stomach was found to be greatly dilated. Its external 



THE AFTER TREATMENT IN OVARIOTOMY. 993 

appearance was healthy. It contain 3d about three pints of dirty 
ochre-colored water. On being opened along the whole length of 
its greater curvature, nearly one-half of its mucous surface was 
found to be highly congested, and in a state of violent inflamma- 
tion. Near its middle portion, and along the larger curvature, 
where three distinct ulcers, the largest of which was as big as a 
three-cent piece. These were in the midst of the inflamed area, 
and were evidently acute and active in character, being partially 
covered with pus. On either side of these recent ulcers was a row 
of dark-colored spots which all who were present recognized as so 
many cicatrices of ulcers that must have healed. These spots had 
the appearance of so many shot-holes, and there were more than 
twenty of them. 

Sometimes this ulcerative tendency is coupled with strange 
caprices of the will, as well as of the appetite in old dyspeptics. 
Such patients have little pluck and fortitude, 
and are discouraged from the outset, or they 
antagonize all efforts to regulate the diet and to get them through 
without serious trouble on the part of the stomach. On May 17, 
1883, I removed an old poly cyst from a patient, for my friend 
Dr. C. W. Crary, now of Kenwood, 111. The woman was 62 years 
old, a theomaniac, and therefore a confirmed dyspeptic, who did 
not caro. to get well, but who did "want to go to Heaven." She 
floundered through thirteen days of convalescence, gave the doc- 
tor and the nurses the greatest trouble and anxiety by rolling 
about and doing everything by contraries, and ended the scene 
by eating a lot of indigestible food. There were no septic symp- 
toms and the wound had united perfectly. The autopsy disclosed 
deep ulceration at three different points in the mucous membrane 
of the duodenum. 

Although we generally advise to have the urine drawn every 

few hours during the first afternoon and night, it is best to 

encourage the patient to pass it in a natural 

The urine. . 

way. Without the clamp there is no drawing 
of the pedicle over the fundus of the bladder and its gradual dis- 
tention can do no harm. By voiding it herself she is spared the 
strangury and the catarrh of the bladder and of the urethra which 
used sometimes to last for weeks. ' Much discomfort has been 
saved the patient by her being allowed to empty her bladder her- 
self, and not having this done for her. Why the catheter should 
be passed two or three times a day I have never been able to 
understand, when the patient can almost always accomplish this 
for herself. It was the rule, I suppose, just as it was the rule to 
have the bladder emptied before operation." (Keith.) 

Partial or complete suppression of the urine is a serious symp- 






994 THE DISEASES OF WOMEN. 

ton. It either signifies that the bladder or the ureters have been 
injured during the operation ; that the patient labors under an 
old renal disorder; or that, from the use of the sulphuric ether, 
from the shock, or from some similar cause, the function of the 
kidneys has been suspended. The risks from uraemia added to 
those of septicsema are very great, and therefore, as soon as possible 
the flow must be restored. Aconite, apis, belladonna, hyoscyamus, 
or a kindred remedy may be indicated, and warm moist cloths 
should be applied to the pudenda. If the stomach will bear them, 
diluent drinks should be freely given. Thornton advises an 
expedient which, although it would seem to be hazardous, may 
yet be permissible in extreme cases, which is to bare the patient's 
arms and to pack them in towels that are kept wet with ice-water. 
Even in the simplest cases it is best to prevent the bowels from 
becoming constipated. Laxative food and cooked fruits may be 
allowed, if everything goes on well, after the 

bow h eis. ondition ° f the close of the first week - Nux vomica, lycopo- 
dium and kindred remedies are often useful. 
Rectal enemata of warm water are almost always grateful, and 
may be repeated, if the patient does not object, every third day, 
beginning at the fifth or sixth day. In some cases the mineral 
waters, especially Hunyadi water, are to be preferred. Hyper- 
catharsis is harmful unless an attack of peritonitis is imminent. 
I am fully persuaded of the efficacy of saline cathartics where 
there are signs of peritonitis following an abdominal section. 
The old idea that the bowels should be cramped 
compiS£ns erit ° neal an d put into a state of paresis with opium was 
all wrong; and so also was the practice of neg- 
lecting them altogether. Tait's habit of giving the sulphate of 
magnesia every hour until the bowels are moved is an invaluable 
resource where the pulse and the temperature are increased, the 
discharge from the drainage tube has stopped, or nearly so, and 
the local signs of peritonitis are present. The action of the drug 
can be facilitated by enemata of warm soap-suds; and the free 
watery stools that follow will secure a kind of intestinal drainage 
that will avert the threatening inflammation, just as a free sweat 
may abort a fever. He says: "If these symptoms advance to 
an alarming extent, I use still more active measures to get the 
bowels moved, because I always find that as soon as a motion 
has passed they rapidly disappear ." Whenever these symp- 
toms arise, if the bowels have not moved spontaneously and 
freely, we may have recourse to this expedient, beginning, if 
necessary, as early as the second day after the operation. 

Directly the wound is closed, especially if the adhesions were 



THE AFTER TREATMENT IN OVARIOTOMY. 995 

extensive, there will be a more or less free discharge of bloody 
serum into the abdominal cavity. The quantity 
agetabe.^ ° f the dram ~ * nus secreted sometimes amounts to a pint or 
more without doing any harm, provided only, 
that it is not retained within the peritoneum. The object of the 
drainage tube is to collect this fluid and to convey it out of the 
body. That tube will also notify us of the existence of any 
secondary haemorrhage, with which the serous flow must not be 
confounded. To prevent the accumulation of serum in the Doug- 
las pouch, which is the most dependent portion of the abdominal 
cavity, the glass tube should for the first few days be carefully 
emptied at regular intervals. For this purpose the corners of 
the rubber cloth are turned back and a bit of clean, carbolized 
rubber tubing to which a syringe is attached is dropped into the 
glass drain, and the serum is sucked out of it very slowly and 
carefully. The tubing may be used as a syphon for the same 
purpose; or you may pass the long nozzle of a clean, hard rubber 
uterine syringe directly down the glass tube and so withdraw the 
mischievous serum. The rubber-dam should afterwards be closed 
as snugly as at its first application. In bad cases this little oper- 
ation should at first be repeated every three hours, but, if all 
goes well, it will not be necessary after a little to make it so often. 
In from one to four days, if the serum has lost its color and the 
patient's temperature is not above 100°, the drainage tube may 
be withdrawn, great care being taken to keep its old site covered 
and protected by antiseptic gauze until it has healed by granu- 
lation. 

Happily the dressing of the wound is now reduced to the min- 
imum of simplicity. If all goes well the only thing to do for the 
first week is to let it alone; and after that to 

Dressing the wound. , ., -i • i , i -i , i ^ n • 

keep the binder, the gauze and the clothing 
clean and sweet. The dry applications that were made when the 
wound was closed will secure union by the first intention, and 
that is exactly what is wanted. The pedicle is safely within the 
abdomen, where it belongs, and the serum that exuded is safely 
outside the peritoneum, where it can do no possible harm; and so 
the local conditions of repair arid of recovery are all that could be 
desired. Further on, if there are stitch-hole abscesses, or mural 
abscesses, or if there is evidence of suppuration along the margins 
of the wound, the topical use of calendula and the removal of the 
cotton, will be necessary. If the discharge of pus is free, or long- 
continued, silicea should be given internally, and a good nourish- 
ing diet ordered. If there is any odor to the discharge, an anti- 
septic may be added to the calendula lotion. 



996 THE DISEASES OF WOMEN. 

It is only in extreme and very exceptional cases that it ever 
becomes necssary to reopen the abdominal incision. If the drain- 
age tube fills, and continues to fill with real 

Beopening the wound. , , -. -,., . P . « . -, . 

blood, and there are manliest signs or sinking 
from internal haemorrhage, some and possibly all of the sutures 
should be removed, the wound reopened and the pedicle and the 
site of the adhesions carefully examined to find the source of the 

mischief. Whatever it is, and wherever it is, 

h The secondary h^morr- thQ mogt prompt and thorough measures should 

be taken to overcome the difficulty, after which 
the peritoneum should be carefully cleansed and closed. Second- 
ary haemorrhage is sometimes induced by excessive retching, by 
rolling in the bed, or by getting up suddenly, and by the slip- 
ping of the ligatures in the pedicle. It sometimes happens in 
women of an hsemorrhagic diathesis, and in those in whom the 
pedicle is old and unsound. In the Medical Record for this 
month (Nov. 12, 1887) you will find the report of a very remark- 
able case in whicft- the abdomen had to be reopened in a hsemorr- 
hagic subject, and in which life was saved after extreme loss of 
blood by the transfusion of salt and water. A favorite solution 
for this purpose is that of Mikulicz, which is composed of the 
carbonate of soda eight grains, chloride of sodium one and a-half 
drachms, dissolved in one pint of warm distilled water. Of this 
solution twelve ounces may be slowly transfused into the radial 
artery or the radial vein. 

If pysemic conditions are developed and you are satisfied that 
suppuration has taken place within the peritoneum, you may open 
the wound at its lower angle sufficiently to 
bathf intra " peritoneal allow the passage of the aspirator - canula, 
through which the contained serum, or pus, may 
be withdrawn and the cavity afterwards flushed and cleansed. In 
one of Dr. Peaslee's cases this washing out of the abdomen was 
continued for fifty-nine, and in another for seventy-eight days, 
and both patients recovered. 

The following history shows what this expedient accomplished 
in one of my worst cases under the old clamp-and-no-drainage 
method : 

Case. — Mrs. B., aged twenty-five, was sent to the hospital by Dr. 
W. A. Allen of Rochester, Minn. She was a small and very deli- 
cate woman naturally, and was in a very weak condition when she 
came to us. I made the operation in the old hospital building, July 
6, 1880. There were present as assistants Drs. Shears and Paul, 
house physicians, and Drs. E. S. Bailey, C. E. Laning, A. K. Craw- 
ford, and" B. L. Reynolds. The cyst was a compound one, and 



THE AFTER TREATMENT IN OVARIOTOMY. 997 

attached both anteriorly and laterally by adhesions that were very 
firm and vascular. Listerism was freely used to prevent infection, 
for several of the sacs were so attenuated that, in spite of the great- 
est care, they were ruptured before the tumor could be delivered. 
The remaining cysts, which were afterwards opened in the presence 
of the Clinical Society, were many of them endogenous, and num- 
bered in all about one hundred. The tumor weighed thirty pounds. 

She reacted well, but the second day suffered from nausea and 
distention of the stomach with gas, and finally vomited a dark 
green fluid. This gastric irritability continued at intervals, with 
great thirst, flatuence, and intolerance of food, for three weeks. 
The clamp dropped on the seventeenth day, at which time a swell- 
ing had formed on each side of the bladder. On the twenty -third 
day the abscess found vent about the pedicle, and a large quantity 
of dirty grayish fluid with a foul odor escaped. At evening the 
abdomen was filled with a weak solution of chloride of sodium in 
slightly carbolized water at a temperature of 102°, which was 
thrown through the canula of the aspirator and afterwards with- 
drawn by the same means. The overflow was mopped with sponges, 
and the cavity of the peritoneum was thoroughly cleansed and irri- 
gated. This operation was repeated five times in all on alternate 
days, and always with comfort and relief to the patient. The 
second time that it was made nearly a pint of stinking pus was 
first taken by the aspirator. On the twenty-ninth day another large 
abscess, which was located between the lower angle of the wound 
and the pubes, and which contained half a pint of pus, was dis- 
charged. 

The stomach did not recover its tone, nor did the appetite return 
until after the flushing of the abdomen was begun. Besides, the 
pulse was not below 100 three times in three weeks until after the 
first abdominal injection. The highest temperature was 103°, the 
total variation, however, was only about two degrees. She made 
a final and complete recovery. 

Secondary drainage, if necessary, should be made with a soft 
rubber instead of a glass tube. It is not very satisfactory, how- 
ever, unless the noxious fluids are easily accessible, in which case 
the tube may lie beneath and parallel with the 

For secondary drainage. -. ^ -, , p, ,, .-i j_i a • i 

wound, and may be lett there until these fluids 
are thoroughly drained off. The outer end of the rubber tube 
which can be pierced and fastened to the binder with a safety- 
pin, must be carefully covered to prevent the admission of air 
into the peritoneal cavity. 

The object of placing the superficial sutures with catgut is that 
the wound need not be disturbed until the time has arrived for 

removing the deeper ones. That time varies 
S nto e es. emoval ° rthe from a week to ten days. If the wound is 

dry and sweet, and the line of union is perfect, 



998 



THE DISEASES OF WOMEN. 



The convalescence and 
the first getting up. 



and especially if the tumor was a very large one, or if the abdom- 
inal parietes are very thick, it is better to leave them until the 
tenth day. But if they excite redness or irritation, or if either of 
them acts like a seton, has gotten loose, or cuts into the tissues, 
it should be taken out. Now that the rule is for recovery to follow 
without suppuration, I prefer to leave the sutures a few days 
longer than was the custom some years ago. They do no harm 
and certainly afford additional security against a ventral hernia. 
It is good practice to remove a few of them at one time, say each 
alternate one, leaving the others for a day or two longer. For a 
day or two at least, after they are removed, the patient should 
not be permitted to lie upon either side. The abdomen must be 
carefully and constantly supported by adhesive straps and a 
binder, which latter, in the form of a snugly-fitting abdominal 
belt, should indeed be worn for six or more months after she is 
about again. 

The duration of the convalescence is by no means uniform. It 
is not safe for the patient to leave her bed within the first fort- 
night, and circumstances may require her to 
remain therein for five or six, instead of two 
weeks. The older the patient and the worse 
the character of the contents of the tumor, the more tedious the 
recovery, and the greater the risk of the first getting up. Three 
years ago I removed a large multilocular tumor from an old lady 
at Eochelle, 111., the patient of Dr. W. A. McDowell. The tumor 
was chiefly colloid and solid, and the adhesions were very bad. 
Through good nursing and care on the part of the doctor and her 
own daughter, she progressed so favorably that on the twenty- 
first day the doctor told the family that it would not be necessary 
for him to come again. The next day, while the daughter was 
out of the room for a few moments, the old lady conceived the 
idea of surprising her, and so got out of bed and walked to the 
rocking-chair ; but when the daughter returned her mother w T as 
dead ! She probably died of pulmonary embolism. 

The safer way is to prop the patient in bed, and gradually to 
bring her into the upright position. At first she should not be 
permitted to sit up but a little while at a time, the abdomen being 
carefully supported meanwhile. Little by little the length of 
these sessions may be extended, and finally she can stand and 
walk with safety. 

Women who are predisposed to respiratory affections are likely 

to have trouble during their convalescence from 

broncn\tfs e ^nd a P n C eunTo- ovariotomy. Elderly women are more subject 

ma " to bronchitis, broncho- pneumonia, and catarr- 






THE AFTER TREATMENT IN OVARIOTOMY. 999 

hal affections of the air passages than those who are under fifty. 
If the operation was made in bad weather, or if it becomes stormy 
afterwards, these cases will require special care to prevent them 
from taking cold; and the first signs of a coryza, angina, or a 
cough, must be prescribed for promptly. Sometimes an ambitious 
woman will have overdone and exposed herself so as to contract a 
severe cold directly in advance of the operation, in which case 
she will enter upon it just as others do upon labor, only to develop 
some after-coming disorder. Mrs. M., living at 116 Gurley street, 
the mother of nine children, and 44 years old, cleaned, scrubbed, 
and helped to whitewash the room in which I afterwards oper- 
ated. She did much more beside, and contracted a severe cold 
in advance of the operation. The tumor, which was very con- 
densed and solid, was removed entire through an incision of 
fifteen inches. The omental adhesions were so extensive and 
vascular that it was necessary to ligate and to excise a large 
portion of that structure en masse. On the second day she had 
pains in the left chest and shoulder and a harassing cough. The 
case developed into a serious attack of broncho-pneumonia, which 
was not fully overcome until after the fifteenth day. The high- 
est temperature noted was 102-5°, and the highest pulse 130. 
She convalesced slowly, but made a complete recovery. 

More rarely there is a swelling of the parotid glands, such as 
sometimes follows other abdominal and pelvic operations, inclu- 
ding Emmet's operation for a lacerated cervix, 

Parotitis. . 

and the operation for vesico-vaginal fistula. 
This form of mumps is either of a sympathetic or of a septic 
origin. It may become pyemic, and sometimes the periosteum 
of the inferior maxilla is involved. Warm applications arid em- 
mollients locally, and mercurius, belladonna, or other indicated 
remedies should be given internally. This "parotid bubo" should 
not be lightly regarded, even although it may not be attended by 
grave constitutional symptoms. The glands do not always sup- 
purate, although the lesion is more likely to arise during the 
second or third week. Dr. Goodell is evidently right in suppos- 
ing that, while this complication may follow ordinary surgical 
operations, it is more liable to happen after those which have 
been made upon the sexual organs; and that the sympathetic 
form of this "parotid bubo" which is independent of blood-poison- 
ing is not necessarily dangerous. 

If the patient makes a special complaint of pain in either leg, 

and of a sensation as if it were swollen, and big- 
th?Sus i . s, pblegmasia ' ger than its fellow, particularly if the tumor 

has been a very large one and has pressed upon 



1000 THE DISEASES OF WOMEN. 

the corresponding side of the pelvis, you may find local evidence 
of phlebitis, or of infiltration of the cellular tissue below the 
knee. This condition sometimes develops into a confirmed 
phlegmasia, and extends to the thigh, from which state it may 
easily pass on to suppuration, and become very painful and 
serious. Absolute rest with the affected limb in the horizontal 
position; hot applications, either wet or dry, as they are most 
grateful; wrapping the leg in cotton, and internal remedies as 
for a "milk leg" are the chief indications for treatment. Throm- 
bosis of the vein is possible in such a case, and the prognosis 
should be guarded. 

"Acute mania sometimes follows ovariotomy, especially when 
both ovaries have been removed. The attack is usually tempo- 
rary, but it sometimes ends in insanity, and 

Acute mania. -in • r» • • , 

even in death, as m one ot my own patients. 
Keith, Thornton, Tait, Bantock, Bryant and other leading ovari- 
otomists report analagous cases." (Goodell.) 

I have never seen a case of insanity following this operation, 
but, in November, 1882, I made an ovariotomy in the person of 
a woman who had suffered from a form of mania for many months, 
and who had been confined in an asylum for the year previous to 
the operation. She made no resistance, took the anaesthetic at 
the request of the husband, and was totally indifferent and 
oblivious to everything. The tumor weighed thirty-four pounds. 
She made a good recovery, but for some weeks did not fully 
regain her faculties. Finally her mental condition was restored, 
she became the mother of a very interesting child, and has 
remained well and happy ever since. 

Pains should always be taken to prevent bed-sores, a precaution 

which is especially important if the patient is 

an old one. This result can be obtained by 

having her changed from one side to the other occasionally, and 

not allowing her to lie upon the back all the time. 

THE RESULTS IN OVARIOTOMY. 

Up to this date (December, 1887), there is not upon record a 
well authenticated, radical cure of a true ovarian cyst by any other 
than surgical means. When this statement is coupled with the 
fact that those who survive the risks of ovariotomy almost always 
recover their health to a degree that seldom follows in other very 
serious operations, we naturally inquire into the rate of its mor- 
tality. What proportion of all of those* who are operated upon 
for the removal of these tumors outlive the immediate danger and 
regain their former health 



THE AFTER TREATMENT IN OVARIOTOMY. 1001 

The results of this operation have improved immensely within 
a very few years, and, I believe, for the following reasons: 

1. The change in the rule advising that it be not postponed 
until the patient is in a desperate strait, where the complications 
loill render her recovery next to impossible. — A month ago I 
showed you an ovarian cystoma which I had just removed from a 
patient of the Drs. Dunn, of Centralia, 111. The woman was 58 
years old, and had carried that tumor for 28 years because her 
old doctor had told her "never on any account to have it tapped 
or otherwise interfered with." Twenty-five years ago it was tap- 
ped and but once. Afterwards it grew steadily and at the opera, 
lion weighed 62 pounds. She is now well again, but it is one 
case in a thousand, for the contingencies multiply very rapidly 
when such growths exceed three or four years' duration. 

It is the age of the tumor and not the age of the patient thai 
subtracts from the chances of recovery after an ovariotomy. Nine 
of my cases have been above sixty years old, and they all got 
well. One of them was a double ovariotomy in a patient of Dr. 
Li. W. Jordan, of Bucyrus, O. The largest tumor would have 
exceeded ninety pounds in weight if she had not been tapped for 
temporary relief just one week before the operation. 

In these old cases there is the double danger of draining the 
vital fluids into the cyst, and of the condition becoming cumula- 
tively septic through a distillation of the contents of the sac into 
the blood. My report to the Clinical Society for July, 1886, 
^closed with the following propositions:* 

1. That the absorption of a part of the cyst contents prior to the 
operation is a not infrequent cause of fatality in ovariotomy. 

2. That this condition is incident to old tumors, to compound 
cysts, and to cases that have been tapped. 

3. That this insidious, pre-operative form of sepsis is most likely 
to declare itself through an irritable state of the gastro-alimentary 
mucous membrane, with repeated attacks of vomiting and purg- 
ing, and to be confirmed at post-mortem by signs of gastric or 
enteric ulceration, 

4. That, if the patient is predisposed to renal or hepatic dis- 
ease, the kidneys or the liver may be the seat of serious lesions of 
function or of structure, which really depend upon this auto, 
infection. 

5. That the cardiac degeneration and involvement which are 
incident to this form of abdominal growths, as shown by Dr. 
Fenwick, may be ascribed to a pernicious anaemia that is of 
septic origin, and which has its source in absorption through 
and from the disintegrating tissues of the walls and partitions 

*The Clinique, Vol. VII, page 268. 



1002 



THE DISEASES OF WOMEN. 



of the cyst, and not alone in the size and pressure of the sac. 

6. That when this septic infection has existed before the opera- 
tion was made the risk of its continuance and recurrence is very 
great, and the danger from it is due to the dyscrasia which it had 
insidiously developed. 

7. That these facts present a new and powerful argument for the 
early performance of ovariotomy, and indirectly explain the 
increasing exemption from fatal consequences afterward. 

Briefly, then, we save more cases since the doctors have quit 
counselling their patients with ovarian dropsy to wait as long as 
possible before resorting to ovariotomy for their radical cure, and 
since the temporizing and harmful expedient of tapping has gone 
out of fashion. If these old notions had been dropped fifty years 
ago McDowell's operation would have made a much better record. 

2. The improved technique of the operation itself, of the peri- 
toneal toilet, and of the after-treatment. — In this and in the pre- 
ceding lecture we have carefully considered each and all of these 
points in their proper connection. No ovariotomist, whether he 
be great or small, old or young, a beginner or a veteran, can 
afford to disregard the proper and essential prophylaxis of peri- 
toneal surgery, or the conditions upon which this particular kind 
of work is either expedient or successful. 

"Our best English operators — Keith, Thornton, Bantock and 
others — in the last few years had brought their death-rate down 
to the marvellously low figure of about ten per cent., more or less, 
when Lawson Tait's record beats all, by the extraordinary result of 
one hundred and thirty-nine cases without a death, and a general 
mortality over several hundreds of cases of less than five per cent. 
Surely this is the ne plus ultra, not only of abdominal surgery, 
but of all surgery. If it is not a justification for the performance 
of ovariotomy, wherever an ovarian tumor exists, it is undoubtedly 
a stern command to all who seek to perform the operation, so as to 
give their patients the best chance of life, to spare no pains to per- 
fect themselves in every detail of attainable knowledge. {Greig 
Smith. ) 

In a recently published record of his last series of one hundred 
cases, Dr. Thomas Keith, of Edinburgh, reports that he had only 
three deaths to ninety-seven recoveries. These remarkable results, 
which have not as yet been duplicated in America, did not spring" 
from accident or chance, but from a careful application and adap- 
tation of such rules and precautions as I have now given you. 
And they show most conclusively that, other things equal, the 
measure of success obtained increases in ratio with the special 
experience of the operator as an ovariotomist. 



LECTUBE LXI. 



OVARIOTOMY BY ENUCLEATION. 



Ovariotomy by enucleation. Miner's method of. Cases that are suitable for. Ludlam's method 
of enucleating an ovarian cyst. Case. — Ovariotomy by partial enucleation. Vaginal 
ovariotomy. Cases adapted to. Mode of operating* A new hint. The after-treatment. 

There are other modes of performing ovariotomy which remain 
to be descri bed and illustrated before we dismiss the subject. One 
of these is what is called ovariotomy by enucleation, which was 
first proposed and practised by Prof. J. F. Miner, 
cieli?o e n. Smetb0d0f enU " of Buffalo, N. Y.,* and which has been variously 
modified for the purpose of adapting it to a 
wider range of cases. As originally performed this plan consisted 
in fact, in the separation of the pedicle from its attachment to the 
tumor in the same way that the adhesions are usually detached, 
id est by a finger-dissection. Following this mode of separation 
there was no need of torsion, neither of the ligatures, nor yet of 
the clamp, for the torn vessels soon ceased to bleed, as in the 
separation of other adhesions. Dr. Miner says : — "Externally the 
ovarian tumor has a dense firm covering, and the vessels which 
sustain the growth enter it, if at all, only of capillary size. The 
attachment of the pedicle to the cyst is much more easily broken 
than any one would suspect who has not attempted its separation 
in the manner described. The same efforts which are made to 
separate the adhesions elsewhere if extended to the pedicle, will 
be found equally successful. The finger should be introduced 
under the central portions of the pedicle, fully clown upon the 
cyst, and by a gentle elevation followed out along the fasciculi of 
vessels as they extend over the walls of the tumor; nothing can 
be more easy of execution, or more readily accomplished." 

The cases to which this method of enucleation is especially appli- 
cable are those tumors which have broad and short pedicles that 
would be difficult of management either by the ligature or the 
clamp; those ovarian tumors which have no pedicle whatever; 

*The American Journal of the Medical Sciences for Oct. 1872, p. 391. 

1003 



1004 THE DISEASES OF WOMEN. 

and those cases in which the anterior wall of the cyst is covered 
by a sub-peritoneal vascular membrane, which makes it imprac- 
ticable to finish the operation in the usual way, 

bie a for. tbatareSUita " but in wllich [t is expedient to cut through 
this membrane very carefully, and afterwards to 
enucleate the tumor. It is also safer and more successful in sin- 
gle than in compound cysts. 

Some years ago I first practised a method of enucleation, which 
adds a new resource to the management of cases in which the 
adhesions are so general and so formidable as 
eau U ciea^>n meth0d ° f otherwise'to force one to relinquish the removal 
of the tumor. This plan, which [ had never 
heard of betore, consisted in the separation ot the coats of the 
cyst wall, in removing its lining membrane entire, and in leaving 
the matrix without disturbing any of the peri-cystic adhesions or 
visceral attachments. The records of this remarkable case were 
carefully preserved, and read as follows : 

Case. — Mrs. H., of this city, aged 22, is the mother of one 
child, which is two years and eight months old. Five years ago, 
at the age of seventeen, she began to have a pain in the region 
of the left hip, and the left side, sometimes extending- down the 
left leg. For some time the side had been weak and the pain not 
very severe, when she slipped and feel so as to strain the side 
severely. After this accident she suffered occasional paroxysms 
and attacks of acute pain, one of which lasted a whole week. 

She first observed an enlargement in the left iliac and ovarian 
region four months after her marriage. This was accompanied 
by a general bloating of the abdomen, which would subside and 
at times almost disappear. Then she became pregnant, and 
towards " term" her size was " enormous." She had a natural 
labor, and got up well, weaning the child wnen it was thirteen 
months old. 

In a month after the birth of the child, however, she had a 
severe attack of peritonitis. Then the tumor grew and filled 
rapidly. For some months she had local electrical treatments 
which caused the growth to diminish somewhat in size. During 
two weeks of this time she took a "treatment" of this kind 
every day on the doctor's theory that the enlargement was due 
to dyspepsia, which he told her arose from drinking coffee! 

In all she has had fourteen physicians, each of which has given 
a different diagnosis. One said she had dropsy and an ovarian 
tumor. Another decided that the ascites was so pronounced as 
to prevent a recognition of the ovarian tumor, if there was one. 



OVARIOTOMY BY ENUCLEATION. 1005 

A third treated her for about three months for a " fattening of 
the apron" (omentum?) which " fattening," it was said, " pre- 
vented the escape of the wind and so caused the abdomen to 
become enlarged!" 

During the past two years she has had repeated attacks of 
what, from her description of the symptoms, appears to have 
been sub-acute peritonitis. These were generally induced by 
active exercise while on the feet, as for example by ironing, or 
by standing for a long time while cutting out garments Not 
unfrequently these fits of illness would either accompany or fol- 
low the menstrual period. The menses had been and continue 
quite regular. In former years the flow was very free, but of 
late it is becoming more scanty. The general health is good, the 
appetite fair, but at times she cannot lie down and sleep, owing 
to the dyspnoea caused by the mechanical pressure of the tumor 
against the diaphragm. 

The measurements (Aug. 2, 1873), were as follows: The cir- 
cumference of the body over the umbilicus was 37 inches ; 
from the ensiform cartilage to the pubes, UJ inches; from the 
ensiform cartilage to the umbilicus, 8 inches ; from the umbilicus 
to the pubes, 6 J inches; from the anterior superior spinous pro- 
cess of one ilium to the other, 14J inches; from the right ante- 
rior superior spinous process obliquely to the point of left float- 
ing rib, 19 J inches ; and from the left ditto to the point of the 
last floating rib on the right side, 16 J inches; depth of the 
uterus, 2f inches. 

The operation was made at the patient's residence, at 12:30 
p. m., on Tuesday, October 14th, 1873, ten days after the cessa- 
tion of the last menstrual period. There were present Drs. W. 
Danforth, C. N. Dorion, and R. K. Paine, of the Hahnemann 
Hospital, and Messrs. C. D. Stanhope, H. W. Roberts and G. R. 
Parsons, of the college class. Dr. Paine administered the ether, 
and my colleague, Dr. Dorion, was my chief assistant. Although 
none of us had ever witnessed the removal of an ovarian tumor 
by any form of enucleation, I had previously determined upon 
this mode of procedure, more especially because it was evident 
that the cyst was bound on all sides by adhesions, resulting from 
the frequent and severe attacks of peritonitis to wdiich my patient 
had been subject. 

I made the incision, as usual, along the linea alba. At first it 
was only four inches in length, but it was afterwards enlarged to 
five inches. There was but little haemorrhage. Anteriorly the 
adhesions were so intimate and firm that it was only by the escape 



1006 THE DISEASES OF WOMEN, 

of the abdominal fluid at the lower end of the incision, and the 
application of Atlee's test that we were certain that the peri- 
toneal cavity had been opened. The sound was passed beneath 
the umbilicus, but would not glide over the anterior surface of 
the tumor at all. A slight separation of the adhesions was at- 
tempted on each side of the incision, sufficient to prove that they 
were very compact and very vascular. This fact was so obvious 
that all the physicians present expressed themselves as satisfied 
that the operation must be abandoned, or the patient's life would 
be put in great peril by completing it after the old method. And 
this state of things caused me to renew my resolution to test the 
expedient of enucleation. 

At a glance it was evident, however, that the mode of perform- 
ing this operation as first recommended and practised by Prof. 
Miner, was impracticable. The tumor could not be turned out 
upon the abdomen, and the adhesions were in the way of getting 
at the pedicle. Therefore, in order to separate the cyst, we could 
not begin " under the central portion of the pedicle," but had to 
content ourselves with first detaching it at a point opposite the 
abdominal incision. 

Now this, as you may suppose, was a very delicate matter. 

The peritoneal layer being very thin, and the cyst- wall likewise, 

the o'reatest care had to be exercised in be^innino- and in corn- 
to O C 1 

pleting their dissection and detachment. A very slight incision 
was first made, and then the handle of the scalpel was used to 
carry on the separation until it was sufficiently extended to allow 
of the fingers being employed in the same way. It was only with 
extreme care and patience that this part of the operation was 
performed, for the cyst required to be separated in this manner 
throughout its whole circumference. Indeed it took Dr. Dorion 
and myself nearly three- fourths of an hour to accomplish this 
object. And during all this time we exercised the precaution 
not to lift or to disturb the matrix of the tumor, lest we might 
rupture some delicate adhesions on its posterior surface, and 
thereby cause a concealed internal haemorrhage. 

The diagram on the black-board will give you a pretty correct 
idea of the pathological anatomy of the tumor, and also ot the 
relative position of the tissues which were separated during the 
operation. 



OVARIOTOMY BY ENUCLEATION. 1007 

Having finally removed the cyst, we were prepared to appre- 
ciate Dr. Miner's remark: 

" No surgeon in the world was ever more surprised at what he 
had done than myself, when I found that I had removed a large 
ovarian tumor without ligating a single vessel, and without any 
haemorrhage worthy of notice." 

Here we had taken out this large sac without having applied a 
ligature, or resorted to torsion, or anything of the kind; and 
what was equally remarkable, without having seen the intestines, 
the uterus, the opposite ovary, or even the pedicle! It really 
seemed as if some important step in the operation had been 
omitted. 

But it only remained to clean the hull of the bloody serum 
which had oozed from the capillaries. After waiting a quarter 
of an hour, in order to be certain that ksemorrage would not set 
in, the abdominal incision was closed with silver sutures in the 
usual way. The cut was dressed with a compress moistened with 
a mixture consisting of the tincture of calendula, glycerine and 
warm water, in equal parts. The whole was secured with adhe- 
sive straps and a binder, and the patient put to bed again. The 
entire operation lasted two hours. The cyst and its contents 
were estimated to weigh thirty pounds. 

She rallied well, and the anaesthesia passed without any ill 
effects. She vomited but once. Aconite 2 and atropine 3 were 
given at intervals of an hour. At 7 p. m. she slept quietly, but 
at bed-time was harassed with a nervous cough, which was re- 
lieved by ignatia 3 and by taking half-teaspoonful doses of pure 
glycerine occasionally. 

The aconite was continued until the fourth day, when the 
menses appeared. At 3 p. M. she had quite a severe chill, with 
dyspnoea, which continued for half an hour. Re-action was induced 
by friction, the application of dry heat, and by the internal use of 
stimulants. The usual precautions were taken each day thereaf- 
ter to prevent the recurrence of the chill, and with success, but 
the dyspnoea came at 4 p. m. every day for a week. 

On the fifth day she took meicurius sol. 3 and bryonia alb. 3 
every two hours alternately for the white pasty tongue and the 
cough. In the afternoon two of the deep sutures were removed, 
and she was turned upon her side for the first time. 

On the sixth day, from 7 to 10 p. m. she was very restless, and 
was troubled with a nervous cough, for which she took spongia 



1008 THC DISEASES OF WOMEN. 

instead of bryonia, with arsenic nn: alb. 3. She had also a fre4. 
warm perspiration for the first time at 8 p. x. 

At 3 a. m. of the seventh day she had a sHght epistaxis, which 
continued for ten minutes. The blood lost was of a very dark 
color. At 4 p. m. she had a violent desire to urinate, but, although 
the quality of the urine was unchanged, the quantity was very 
small. The evident exacerbation of the symptoms at early even- 
ing, and the continued high range of the temperature, led us tn 
prescribe quinine, which was given for several days, at the rate of 
three grains per diem. The remaining sutures were removed. 

On the ninth day, at 5:25, a. m., she had a return of the nose-- 
bleed as before. The bowels were moved by an enema, and her 
clothing was changed. There was also slight abdominal tympan- 
itis, for which belladonna and arsenicum were prescribed. In the 
afternoon, while she was lying for a short time upon her leftside, 
a copious discharge of a thin, brown, serous fluid took place from 
the openings left by the sutures. 

The tenth day was characterized by greatly increased difficulty 
ot breathing after 3 p. m., the number of respirations being thirty- 
six to the minute; and by the temperature reaching 105° in the 
vagina at 9 p. m. In order to be certain that there had been no 
mistake in the latter regard, the thermometer was passed into 
the urethra, and the result was the same. 

The next day the breathing indicated thirty-two respirations to 
the minute, and the pulse and temperature had also fallen. 

When the wound was dressed on the twelfth day, there had 
been a free discharge of a thick, brownish, inoffensive and gelati- 
nous fluid from the lower extremity of the incision, and a healthy 
yellow pus from the openings of the sutures. 

On the fourteenth day, the purulent discharge being still copi- 
ous, silicea 3 was given. The menstrual flow ceased at this date,, 
and the urine was passed for the first time voluntarily. 

The day after, the bowels moved. 

From this date the patient gradually improved. She slept and 
ate very well, was in good spirits, and sat up the first time for 
about fifteen minutes on the twenty-third day. The pulse and 
the range of temperature were taken and carefully recorded each 
morning and evening for three weeks subsequent to the opera- 
tion. 

The free formation and discharge of pus in this case suggests 

the propriety of securing its drainage from the lower extremity 

of the incision in all cases of enucleation espec- 

^Necessity for drain- ^^ rpj^ mfty be doRQ 1)y keepino; the l ower 

part of the wound from uniting, either by the 
introduction of a sponge tent, or ot a silk thread, a silver wire, or 



OVARIOTOMY BY PARTIAL ENUCLEATION. 



1009 



even of a gum elastic drain-tube, or of a catheter. The objection 
to the drain-tube, however, would be that, by lying in direct con- 
tact Avith the interior of the shrunken sac, its presence would be 
likely to increase and to prolong the suppurative process. 

TABLE OF THE TEMPERATURE AND THE PULSE. 



DAY. 


FIRST. 


SECOND. 


THIRD. 


FOURTH. 


FIFTH. 


A. M. 1 P. M. 


A. M. | P. M. 


A. M. | P. M. 


A. M. | P. M. 


A. M. | P. M. 


Pulse 

Temp' r'tui*e 


. . . . I 120 
. . . . 1 103 


120 1 120 
102 | 103 


11)0 j 106 
101 3-5 i 102 


104 1 108 
101 1 103 


108 1 108 
101 3-5 1 101 3-5 


DAY. 


MXTH. 


SEVENTH. 


EIGHTH. 


NINTH. 


TENTH. 




A. M. | P. M. 


A.M. I P. M. 


A. M. 1 P. M. 


A. M. | P. M. 


A. M. | P. M. 


Pulse 

Temp'r 'ture 


106 1 112 
102 1-5 1 104 


104 
101 4-5 


112 
104 1-5 


Iu6 1 110 
10:2-5 | 103 2-5 


106 1 100 
1013-5 i 1031-5 


108 i 10t> 
103 1 104 1-5 


DAY. 


ELE ENTH. 


TWELFTH. 


THIRTEENTH. 


FOURTEENTH. 


FIFTEENTH. 




A. M. i P. M. 


A. M. | P. M. 


A. M. | P. M. 


A. M. | P. M. 


A.M. | P.M. 


Pulse 

Temp'r' ture 


100 1 104 

101 4-5 I 103 3-5 


98 1 100 
101 3-5 | 103 2-5 


98 1 90 
101 4-5 1 100 


96 1 98 
101 1 102 


94 1 100 
99 4-5 1 103 3-5 


DAY. 


SIXTEENTH. 


SEVENTEENTH 


EIGHTEENTH. 


NINETEENTH. 


TWENTIETH. 




A.M. | P. M. 


A.M. 1 P.M. 


A. M. | P. M. 


A. M. P. M. 


A. M. | P. M. 


Pulse 

Temp'r' ture 


92 I 100 
100 1 103 2-5 


92 
101 


100 
103 


88 
100 1-5 


84 
100 1-5 


86 
99 3-5 


90 
101 2-5 


.. .. | 90 
»9 1-5 | 102 



111 reviewing this case, I am satisfied that this modification of 
Dr. Miner's operation is an invaluable one. Especially is this 
true where the nature and the extent of the parietal and visceral 
adhesions render it unsafe and impracticable to remove an ovar- 
ian cyst by the more ordinary method. I do not suppose that this 
plan is suited to all cases of unilocular cysts indiscriminately; but, 
in this particular instance, it is evident that my patient owes her 
life to it and to the careful after-treatment and nursing which she 
received. Seven years have now passed (Dec. 1880), and this 
patient has had no return of her old trouble, nor any abdominal 
or pelvic sequels of any kind. 

OVARIOTOMY BY PARTIAL ENUCLEATION. 

There is another mode of extirpating an ovarian tumor, which 
consists in its partial enucleation, by splitting the cyst- wall so as 
to avoid a rupture of its external adhesions. You can readily 
understand that this method, unlike the one just described, is 
applicable to compound as well as 10 single cysts. 

What are called parietal adhesions, or those which fasten the 
tumor to the abdominal walls, can be stripped off carefully by a 
finger-dissection ; or, if they are stringy, firm and vascular, can be 
ligated and cut, as already directed. But the visceral attachments 



1010 THE DISEASES OF WOMEN. 

of the tumor to the intestines, the liver, the uterus and the blad- 
der, and the pelvic adhesions that sometimes anchor it in the 
Douglas pouch, and to the rectum, must be disposed of by some 
other method. The latter represent the class of cases in which, 
only a few years ago, the operation of ovariotomy was relinquished 
as soon as they were found to exist, and the incision was closed 
without any further attempt at the removal of the tumor. But 
now, instead of turning these grave cases away to die, Ave make a 
delicate dissection of the coats of the sac, go within its vascular 
shell without rupturing its vessels, take away its lining or secret- 
ing membrane and g'ive them a chance to recover. I certainly 
have saved the lives of five women in this way. 

The difference between this mode ot enucleating the cyst and 
that of which I spoke at the beginning of my lecture, is that in 
this case only so much of the sac as is adherent is separated by the 
splitting process. Beyond the margin of the visceral adhesions 
the cyst wall is cut through and removed in the usual way. By 
this means we leave the patch ol adhesion, no matter how large or 
small it may be, just as it was before the operation, excepting 
that we have denuded it of its lining membrane. 

This method of operating is not new, but has been performed in 
various ways, and sometimes unwittingly, during the last few 
years. It certainly has great advantages over the expedient of 
cutting away the sac, leaving so much of it as was held by the 
visceral adhesions to be drawn forward and stitched into the lower 
angle of the wound without stripping the patch of its secreting 
membrane. The record of one of my most serious cases, one in 
which I successfully removed a tumor weighing eighty pounds, 
will prove its value when other modes are not available. 

Case — Mrs. A., aged forty-five years, ceased to menstruate two 
years ago. Formerly a citizen of Illinois, she moved to Montana 
in the spring of 1871, where she has lived up to the present time. 
Ten years ago she first noticed a swelling in the right inguinal 
region. Its growth was much more rapid the three years preced- 
ing than the three following her arrival at the west. Her health 
was very much improved by the journey to Montana, but the 
swelling did not disappear. During the past tour years the growth 
ol the tumor has been much more rapid. 

For some time before and after her removal the menses returned 
every two weeks. They were not excessive, but were slightly 



OVARIOTOMY BY PARTIAL ENUCLEATION. 101 i 

painful. She has a son sixteen years old, but the tumor is in no 
way connected with his birth. She has never had a miscarriage, 
nor as far as she can remember, a fall or a strain. 

Five months ago she was desperately ill, and almost died from 
protracted vomiting, which continued for five weeks, but with no 
diminution in the size of the tumor. When this disorder had 
ceased, a dropsy of the lower extremities commenced, and the 
calf of the leg finally measured sixteen inches in circumference. 
This effusion extended upwards along the thighs, sides, abdomen 
and back, and was present when she left home for Chicago, Dec. 
27th, 1877. 

Previous to her departure from home, she had not been out of 
the house five minutes at one time in four months. The first four 
hundred miles of the journey were traveled in a farmer's wagon, 
over the principal range of the Rod^y Mountains. The remain- 
ing fourteen hundred were traveled on the railroad. The whole 
journey of eighteen hundred miles occupied two weeks. The 
patient bore the trip remarkably well, and even improved on the 
way. 

My first physical examination of the case was made on elan. 17th 
1878, at the residence of her sister in Elgin, forty miles from 
Chicago, and the following conditions were found to be present: 
The uterus was normal in size, with left lateral version, the cer- 
vix was retracted, the os high up on a line with the symphysis 
pubis. There was no pouching or fluctuation in either cul-de-sac. 
1 found a flatness on percussion all over the abdomen in front, the 
tumor lying chiefly to the right of the median line. The outline 
of the cyst was distinctly made out, on the right side especially. 
On the left there was dullness far back into the lumbar region. 
The wave-line and impulse were both very distinct. There was 
no history of peritonitis in the case, whether puerperal or other- 
wise. The sample of the fluid drawn by aspiration, was of a dark 
claret color, and quite thick. 

The operation was set for Thursday, Jan. 31st, 1878, but on 
account of a severe snow storm was deferred until Feb. 2d, 1878, 
when it was made at Elgin, 111., in the presence and with the 
assistance of Drs. A. L. Clark, H. K. Whitford, C. A. Jeager, D. 
E. Burlingame, C. E. Stone, and Messrs. J. W. Hutchinson and 
W. A. Barker, medical students. 

The operation was begun at two o'clock p. m., and lasted two 
and one-hall hours. On account of venous haemorrhage the abdomi- 
nal incision was made slowly and very carefully. The adhesions 
between the abdominal and cyst-walls, anteriorly, were so intimate 
that it was impossible to separate them, and the cyst was unavoid- 
ably punctured. After the sac w r as evacuated, and it was proved 
that an attempt to detach it in front would, of necessity sacrifice 
the life of the patient, (on account of the extent and vascularity 



1012 THE DISEASES OF WOMEN. 

of the parietal adhesions.) the sac was laid open for the space of 
two inches, and it was determined to resort to enucleation. 

When more than one-third of the lining membrane of the sac 
had been carefully split or separated, (consuming more than an 
hour,) the outer wall was torn through and the remainder of the 
sac, which was not adherent, except to a strip of the omentum 
and also to the rectum, was brought forward and exposed to view, 
as in ordinary cases. 

The pedicle, which was six inches broad and very vascular, was 
tied in three places, with carbolized cat-gut ligatures, but on 
account of venous exudation, and the fear of haemorrhage after- 
wards, it was brought forward and secured by a Thomas' clamp. 
The wound was closed with silver wire sutures, and the incision 
covered with a compress wet in a mixture of calendula, glycerine 
and warm water. Adhesive straps were applied across the abdo- 
men to prevent any possible strain from vomiting. She was put 
to bed carefully, and reacted slowly but surely. 

The fluid contained in the cyst weighed seventy-four pounds and 
the sac itself six, making a total of eighty pounds. The fluid was 
of a very dark chocolate color, slightly acrid, and apparently on 
the verge of decomposition, having changed very materially since 
the previous examination. There was no vomiting until the 
twenty-third day. For the first twenty-four hours, the remedies 
were aconite and arnica in the second dilution. These were fol- 
lowed by verat. vir. 2 at longer intervals, until there were signs 
of suppuration, and the temperature fell to 9 7 J°, which was on 
the morning of the seventh day. On the evening of the sixth 
day, the bowels moved spontaneously, and for some hours she had 
a copious and very offensive diarrhoea, for which she took ars. alb. 
3. For the debility that followed, and which continued for a few 
days only, grain closes of ( he sulphate of quinine were given. A 
slight irritability of the bladder at the twelfth day, was relieved 
by drinking gum-arabic- waier. There was a free, but not a copi- 
ous discharge of pus from the wound after the seventh day, at 
which time a few drops of carbolic acid were added to the solution 
of calendula and glycerine with which the wound has been dressed 
from the first. The clamp did not fall until the twenty-seventh day, 
when the incision was found to have closed perfectly. The urine 
was drawn every three hours, until the close of the seventh day, 
when it was passed naturally. The record of t*he temperature and 
the pulse was taken every morning and evening for four weeks. 

The patient was not free from symptoms of peritonitis until the 
close of the eleventh day. She had a good diet, and the window 
in the next room was kept open most of the time, although the 
air was frosty. For four days after the operation, however, the . 
temperature of the chamber was not below 70°. 



VAGINAL OVARIOTOMY. 1013 

This patient made a perfect recovery, and in due time returned 
to Montana in better health than she had enjoyed for many years. 

I have never before observed so intimate and so extensive a 
union between the abdominal wall and the cyst-wall, as in this 
case. Their surfaces were, indeed, so closely adherent as to defy 
separation, at least without the greatest danger to the patient. 
And I am satisfied that but for the expedient already described 
we should have been forced to relinquish the operation for the 
removal of this enormous tumor. 

The fact is, that when the parietal adhesions rendered its separ- 
ation impracticable, the only way out of the difficulty was to splil 
the coats ot the sac, and to take advantage of the feeble vas. 
cularity of the cyst-wall within its external tunic. This was i 
delicate and tedious process, and the stripping of the first from the 
second layer, (which the clever old nurse compared to the "skim 
ning of a squirrel"), had to be done very carefully. When we haa 
finally reached the limit of the adhesions on the anterior surface 
of the tumor, covering about one-third of the sac, a farther dis- 
section was unnecessary. The outer layer was now broken through 
all around, and the operation finished in the usual way. To avoid 
a recurrent haemorrhage the fasciculus of omentum was ligated 
twice and cut between, as in tying the fuuis after delivery. It 
is evident that the absence of a pre-existing history of peritonitis 
is not always to be depended upon as a sign that an ovarian cyst 
is non-adherent. This is especially true in case the tumor is very 
large, where the pressure is very great and the motion is pre- 
vented. 

VAGINAL OVARIOTOMY. 

The removal of an ovarian cyst by way of the vagina, or vagi- 
nal ovariotomy, was first practised by Dr. T. G. Thomas, of New 
York, in February, 1870.* Prior to that time these cysts had occa- 
sionally been tapped and drained through the floor of the Doug- 
las pouch, but the frequent occurrence of septic infection and pur- 
iform degeneration of the contained fluid with fatal results had 
caused the practise to be abandoned. 

The class of cases to which this mode of operating is especially 
adapted is not a large one, and for many reasons it is not likely to 
become very popular with the profession. It includes those cysts 

*The American Journal of the Medical Sciences, April, 1870. 



1014 THE DISEASES OF WOMEN. 

which are neither very old nor very large, which are retro-uterine 
and pelvic in their location, and are therefore 
ada a ted to wMch ** is accessible through the posterior cul-de-sac. 
Cysts from the size of an orange to that of the 
head of a child which is a year old, that lie in the Douglas pouch, 
and which are moveable, are best suited to this mode of extirpa- 
tion; but it also has been successfully applied to dermoid cysts 
that were small and very adherent. Goodell removed a compound 
cyst in this way, and although his patient was desperately ill, she 
finally recovered. 

Dr. Thomas speaks of the kind of cases to which this operation 
is suited, as follows: 

"It is not my belief that the scope of this plan of performing 
ovariotomy will ever be very great; but I think that in cysts of 
small size, which are unattached, it will offer a valuable resource 
for the avoidance of years of mental suffering while the disease is 
progressing, and of the capital operation of abdominal ovariotomy 
in the end, with all its attendant dangers and uncertainties. Even 
in a doubtful case, vaginal ovariotomy may be resorted to as a ten- 
tative measure, which, in the event of failure from attachment of 
the cyst, would in all probability be recovered from. * * * * * 
I feel sure that it has before it a future of usefulDess for the fol- 
lowing reasons: It is fully as easy of performance as abdominal 
ovariotomy; is evidently attended by much less danger; holds out 
to the patient the opportunity of avoiding many weary months o£ 
suspense in anticipation of that more grave procedure; is equally 
applicable to muitnocuiar and to unilocular cysts; and gives 
abundant facility for securing the pedicle." 

The best mode of performing this operation is to place the 
patient in the dorsal decubitus, just as if you were going to make 

a perineorrhaphy. Then, the vagina having been 
Mode of operating, thoroughly cleansed antiseptically, the perineum 

and the posterior wall of that passage are re- 
tracted with a Sims' speculum. The uterine cervix is drawn down 
and afterwards held out of the way, so as to put the fornix on the 
stretch. Now you are to make a button-hole opening through the 
roof of the cul-de-sac in the direction of a line running from the 
rectum towards the neck of the womb. On pulling down the for- 
nix with a tenaculum, this can be done with a Kuchenmeister's 
scissors, or with a Pacquelin's thermo-cautery. In either case, if 
the tumor lies behind the uterus there will be little risk of injur- 
ing a stray coil of intestine; but you should be careful not to rup- 



VAGINAL OVARIOTOMY. 1015 

ture the cyst, or cysts, before you are ready to empty them with 
the aspirator, or with the simple trocar. 

The adhesions, if there are any, can then be carefully separated 
and ligated if necessary, with fine silk and catgut. Finally the 
pedicle may be pierced with a Skene's needle, a double ligature 
tied tightly about it, and the tumor afterwards cut away. The lig- 
atures should be cut off short before the pedicle is returned to the 
pelvic cavity, and if the intestine hes slipped through the opening 
it should be carefully replaced. 

By most operators it has been thought necessary to stitch up the 
incision thus made in the vaginal roof; but it is better to leave it 
open for drainage, and afterwards to secure immunity from the 
admission of air into the abdominal cavity by packing the vagina 
with two or more soft and clean iodoform sponges. 

This latter item is a part of the practical lesson that we have 

learned from the recent improvement in vaginal hysterectomy. 

Indeed, the expedient of ligating the pedicle 

a new hint. might also be dispensed with by applying a 

Pean's long forceps and leaving them in position 

for twenty-four hours or more. Meanwhile the drainage would 

be perfect and haemorrhage would be impossible. This simple 

expedient might also be extended to the removal of various other 

tumors per vaginam. 

The after-treatment is very simple, but should not be neglected. 
The same precautions should be taken against vomiting, flatulency, 
tympanites, and obstruction of the bowels as were 
The after-treatment advised in the last lecture after an abdominal 
ovariotomy. The sponges should be allowed to 
remain until the forceps are removed (in case they have been 
used), or until there is evidence of a free discharge of bloody 
serum, which will usually be on the second day. The vagina 
should then be cleansed by an injection of clear water at a tem- 
perature of 102°, after which fresh and clean iodoform sponges 
should again be applied. The necessity for repeating this dress- 
ing will vary in different cases; but it can not safely be dispensed 
with until the peritoneal discharge has entirely ceased. 



LECTUEE LXII 



DISEASES OF THE UTERINE APPENDAGES. 

The class of women who are subject to; from imperfect development; from obstructive 
dysmenorrhea; do. puerperal affections; do. gonorrhceal infection; do. membranous dys- 
menorrhoea; tubal and ovarian tuberculosis; in scrofulous subjects: forms of ovarian 
degeneration; varieties of salpingitis; often confounded with kindred affections; the diag- 
nosis of; Fallopian colic; case; the subjective symptoms; the objective do.; the physical 
signs; confusing elements of diagnosis; Battey's and Tait's operations for. 

Under this head we shall speak of those diseases of the ovaries 
and of the Fallopian tubes which from necessity can not always 
have a separate clinical history. They include cystic and atro- 
phic degeneration and sclerosis of the ovaries, and salpingitis, or 
inflammation of the oviducts. 

These organs lie in such close proximity and are so intimately 
concerned in the function of menstruation that their lesions are 
largely responsible for its most obstinate dis- 
classes of women who or( } ers . The classes of women who suffer most 

are most subject to. , 

therefrom include those who are young and 
unmarried; such as have suffered from the diseases of child-bed; 
and married women who have remained sterile. 

It is only too common to find a class of subjects in young girls 
at puberty, who, having reached the age at which the monthly 

flow should be established, are so immature 
o P ment. imperfect devel " ancl so imperfectly developed that nature can 

not assert herself. She struggles to effect the 
discharge and to furnish the physiological sign of womanhood, 
but either the function goes by default, or it is not properly per- 
formed, and an untold amount of suffering is the consequence. 
The different phases of anaemia and chlorosis, dyspepsia, and the 
neurotic disorders, such as hysteria and hystero-epilepsy, are, in 
these later days, clearly traceable in many cases to tubal or 
ovarian disease which has its root in the unsanitary habits and 
surroundings of the school-girl. 

I am persuaded, however, that in the case of girls and unmar- 
ried women salpingitis is more often the consequence than the 

first cause of painful menstruation. For it may 
From acute dysmen- ^ e due to obstructions to the flow that have 

orrhcea. 

originated in the uterine cervix. An acute 
flexion of the womb, or a spasmodic constriction of its neck, from 

1016 



DISEASES OF THE UTERINE APPENDAGES. 1017 

some local or reflex cause, may involve its lining membrane as 
well as that of the tube in such tissue changes as will not pass 
away with the close of the monthly period. And, through the 
want of a ready egress, the arrest or the reflux of blood in the 
tube may easily excite the peristaltic contraction of its muscular 
walls and cause it to become very much distended and painful. 
And thus, beginning with a partial occlusion of the os-uteri, a 
secondary affection, which increases the suffering and complicates 
the case, is finally developed. In former times I certainly have 
cured some of these cases of post-dysmenorrhoeal salpingitis 
unwittingly by first addressing my remedies to the relief of the 
painful menstruation, or to a coincident pelvi-peritonitis, or by 
repositing the uterus before the flow and keeping it in position 
afterwards. 

The puerperal affections upon which the diseases of the uterine 
appendages are most often secondary are endometritis and peri- 
tonitis. When the lying-in woman is ill with 
From puerperal affec- ^ e f ormer affection the inflammation is very 
prone to extend by . continuity or texture until 
it reaches the ovary. And the distillation of the vitiated fluids 
which are sometimes carried from the uterus in septic and 
catarrhal endometritis following labor or abortion may be the cause 
of a long-lasting mischief in the tubes themselves. A large 
share of cases of chronic salpingitis and ovaritis with localized 
peritonitis of a relapsing character, as well as pelvic abscess, are 
due to this cause. When this condition is consecutive upon puer- 
peral peritonitis, the trouble begins at the outer extremity of the 
tube and travels from the ovary through this part of the genera- 
tive intestine toward the uterine cavity. 

Without accepting the life-long theory of Noeggerath, which 
holds that those women who have once been the victims of a 
gonorrhceal infection will never fully recover 
hreaHr^eSiL^ gonorr " from it, we may and must concede that when 
the disease has invaded the organs of which I 
am speaking, the woman will become either transiently or per- 
manently sterile. Like epididymitis in the male, this specific 
form of salpingitis is a secondary affection which may or may not 
involve the ovary; and therefore this tubal Menorrhagia is a 
frequent cause of amenorrhcea as well as of barrenness. 

The wives of such husbands as have been unchaste in their 
youth, and of men of immoral habits who are much of their time 
away from home, are very likely to suffer the evil consequences 
of an infection of which they are the unconscious victims. Even 
when these unfortunate women are neither sterile nor given to 



1018 THE DISEASES OF WOMEN. 

abortion, they suffer from the various forms of peri- uterine 
inflammation that are symptomatic of salpingitis and oophoritis. 

In membraneous clysmenorrhoea the early obstruction to the 
flow, and the prolonged effort to discharge the contents of the 
uterus sometimes results in hyperemia, and 
a*mmorfh<St Tanons haemorrhage and inflammation within the tube. 
This condition not unfrequently determines a 
moderate and transient hematocele. In such a case, especially 
if the moulting of the menstrual decidua depends upon syphilis, 
or upon a repercussed eruption, the exfoliation may extend to the 
lining membrane of the tube. Meanwhile the uterine contrac- 
tions are shared by the fibrous coat of the tube, and the incidental 
suffering and danger are very much increased. 

Genital phthisis is often a cause of inflammation and obstruc- 
tion of the Fallopian tubes. I have already spoken of the com- 
parative frequency of the tubercular deposit 
tuberculoid ovarian within the pelvis. Its most common seat is in 
the peritoneum, and after that in the Fallopian 
tubes. Circumstances will determine whether this lesion of the 
tubes develops early or late in the menstrual life. If the first 
signs of phthisis are thoracic, the tubular involvement of the 
generative intestine may be deferred until after the period of 
child-bearing, or until the climacteric. But, in one who is predis- 
posed to phthisis, if the lungs escape at puberty and the estab- 
lishment of the menstrual function is delayed, or difficult, or if it 
goes by default, the chances of tubal tuberculosis with its accom- 
panying salpingitis are very much increased. Whenever it 
occurs the deposit may be located within the tube so as to obstruct 
its calibre, or in its wall, or outside of it altogether. The result 
is that some form of salpingitis, with an impairment of the mens- 
trual function (to which the tubes as well as the ovaries must 
contribute), is pretty certain to follow. "The tubes are always 
involved in tuberculosis of the genitals, and in about one-half of 
all cases they alone are affected. Beginning in this structure, 
the ravages of tuberculosis are greatest; the specimens in our 
possession show that the disease develops and is most severe at 
the outer extremity." — (Winckel.) 

Akin to this form of diseased appendages is that which some- 
times occurs in scrofulous subjects, in whom the ovaries, as well 
as other glandular structures, are likely to be 
in scrofu ous su jects. j n vo j ve( j < These patients are, pretty certain to 

have chronic uterine leucorrhcea, with periodical discharges of a 
catarrhal kind that evidently come from the Fallopian tubes. Not 
unfrequently this catarrhal flow substitutes the menstrual 



DISEASES OF THE UTE1UNE APPENDAGES. 1019 

discharge ; and whenever you find a case of vicarious leucorrhoea 
you may conclude that in all probability the tubes are in a state 
of chronic catarrhal and purulent inflammation. This tubal 
catarrh is about as common in scrofulous women as the similar 
condition of the Eustachian tube, and which, en passant, is liter- 
ally another form of salpingitis. 

Having considered the etiology of these affections, we must 
speak of their variety and peculiarities. The ovary is liable to 
undergo a species of degeneration that is called 
geiSionf ° varian de " cystic, but which should not be confounded 
with the development of the Graafian follicles 
constituting the ordinary ovarian tumors, or ovarian dropsy. The 
lesion in this case is one in which the cysts remain small, are 
thickened and very much condensed. Their walls often become 
hard and almost cartilaginous, while the parenchymatous structure 
of the organ becomes indurated and cicatricial in character . This 
sclerotic ovary is almost always accompanied by amenorrhoea and 
sterility, and for the simple reason that it usually affects both 
ovaries at the same time. Atrophy of the ovary may be partial 
or complete, and either results in a suspension of the catamenial 
function, as at the menopause, or in great suffering with the 
return of the monthly period. 

The varieties of salpingitis are chiefly interesting because the 
contents of the tumor, when there is one, and of the discharge in 
either case, are not always the same. So far 
gitisf vaneties of salpm " as we are able to judge there is no practical 
clinical distinction between them when exam- 
ined at the bedside, and before they have been removed by an 
operation. In the majority of cases it happens that the extremi- 
ties of the affected tube are closed in consequence of infiltration 
or of atresia, and an accumulation of some kind takes place with- 
in it. This will distend the organ throughout, or in sections, so 
that it may take the form of a sausage, and if it is very large it 
may be mistaken for other forms of pelvic tumor. 

The various kinds of tubal tumors are classified according 
to their contents. If there is a simple, serous, or dropsical accu- 
mulation, the case is one of hydrosalpinx. If it contains pus, 
we call it pyo-salpinx; or if it is filled with blood, we have liazma- 
to-salpinx. There is an accidental variety in which the tumor is 
formed by the accumulation of air that has been forced into the 
tube while giving an intra-uterine injection, which is called physo- 
salpinx. It almost always happens that these tumors by reten- 
tion, as they have been very properly styled, are bi-lateral. In 
exceptional cases, however, one tube may have discharged itself 



1020 THE DISEASES OF WOMEN. 

occasionally, or perhaps periodically, while the other has develop- 
ed a tumor. For this reason the disease is sometimes thought to 
to be unilateral when it is not really so. 

A peculiar interest attaches to those cases of salpingitis in which 
there is a kind of intermittent overflow of the tubal contents 

through the uterus. They are often mistaken 
M Mndred n affeStioL with for ovarian and pelvic abscesses, which in fact 

are seldom if ever relieved in this way. Some- 
times tht, pent up secretion finds vent and because the flow is 
hemorrhagic, the trouble is charged to the uterus when the lesion 
is wholly outside of it. In other cases a copious discharge of 
water per vaginam, and the subsidence of the tumor which before 
had been plainly felt, is taken as evidence of the evacuation, and 
possibly of the cure of an ovarian cyst. It has often happened 
that the gradual escape of these fluids by a sort of decanting pro- 
cess has given relief to symptoms that were supposed to be due 
to a limited, or relapsing peritonitis with more or less effusion. 
It remains to be seen whether, as Wylie and others believe, a bet- 
ter knowledge of the diseases of the uterine appendages, and of 
their clinical history, will show that other forms of peri-uterine 
inflammation are of minor importance. 

In the case of women who are large and stout, with a great 
deal of adipose in the abdominal integument, the diagnosis is 

very difficult and must chiefly be made out 

from the subjective symptoms. For in their 
case there is no such development, distention and attenuation of 
the abdominal parietes as facilitates bi-manual manipulation in 
ovarian cysts and uterine myomata. Whether as a cause or a 
consequence relapsing peritonitis is always a contingent affec- 
tion. The " burning " pains which are referred to the region of 
the ovary either during or after the menstrual period; the pro- 
longed struggle to start the flow in some cases when it is overdue ; 
the occurrence of "menstrual colic' 1 from sudden cold, from get- 
ting the feet wet, or from drinking or eating something that 
causes a chill while the discharge continues, or from forcible and 
excessive coitus, indicates more or less of inflammatory action in 
the tubes. This Fallopian colic, as I have called it in my clinic, 
is often marked by the most atrocious pain and suffering, while 
it may be followed by spasms, epileptoid conditions, hysteria, 
delirium, and the lighter forms of insanity. It is conceded, I 
think, that those cases which are complicated with cystic degen- 
eration of the ovaries are most prone to hystero- or, more prop- 
erly, oophoro-epilepsy. 

This menstrual or tubal colic, which is neither uterine nor 



DISEASES OF THE UTERINE APPENDAGES. 1021 

intestinal, is almost always accompanied by a tympanitic disten- 
tion of the abdomen, and by a decided intoler- 
ance of the sudden jarring of the body. Those 
who have had it once are very likely to have it again. When it 
recurs at the month it usually precedes the flow and is relieved 
by it; but now and then we find a case in which it comes in from 
three to five days after the discharge has ceased, or at a period 
that corresponds with the extrusion of the ovum. I was recently 
consulted in a very remarkable instance of this kind in which 
this symptom was, and had for a long time been pronounced. 

The diagnosis is sometimes obscured by a retro-displacement 
of the womb with an incidental twisting of the tubes. This 
complication is not so rare as it is troublesome and difficult of 
recognition and of relief. Not unfrequently one of the ovaries 
has drifted backwards into the Douglas pouch, where it may 
become anchored by peritoneal adhesions. In other cases the, 
ovary drops into that pocket and remains there temporarily, giv- 
ing rise to morbid symptoms which disappear only when the dis- 
location is relieved. In the patient whose 

C&S6 • 

right ovary and tube I removed in the presence 
of the sub-classes 6 and 7 ten days ago (Nov. 21, 1887), and 
who is almost well again, there was a hernia of the ovary into the 
retro-uterine pouch which sometimes could readily be dis- 
tinguished and at other times could not be found. The remark- 
able fact about her case was that her ill health dated from a strain 
in carrying a bucket of coal up the stairs. Before she reached 
the landing she "felt something give way," after which she fell 
in an insensible condition. That was four years ago, since which 
time she has been subject to fits that border very close upon 
epilepsy, but which have been almost wholly confined to th& 
menstrual period. The only exception to this rule of their recur- 
rence was when, through fatigue or too long standing, she felt 
something fall and press low down in the pelvis in front of the 
sacrum. Whenever that sensation came it acted like the aura 
epileptica, and she never failed to have the fit. Whether the 
operation will result in a radical cure of this unfortunate con- 
dition is doubtful, but, as Prof. Fellows has suggested, it may at 
least put her in a position to be relieved by internal remedies that 
hitherto have been ineffectual. 

The subjective symptoms that are most significant are more or 

less constant pain in the ovarian region, with inability to stand, 

to walk, or to work; nausea, which in some 

The subjective symptoms. . .. , . , . , . ., 

cases is continuous, but which in others recurs 
with the relapse of the local peritonitis; palor, indigestion, 



1022 THE DISEASES OF WOMEN. 

anorexia, emaciation, discoloration of the conjunctiva, obstinate 
constipation, abdominal tenderness with hysterical manifestations, 
dyspareunia and sacralgia ; pain behind or about the uterus, more 
or less menorrhagia, and a profuse intermittent leucorrhceal dis- 
charge, with increased flow and suffering at the month. These 
symptoms are not all present in every case, but, with those which 
have already been mentioned are seldom altogether absent. In 
hematosalpinx there may have been a continuous uterine haemorr- 
hage which has lasted for years, and which has defied the usual 
methods of treatment. In pyosalpinx the tube may become so 
distended with the gradual accumulation as to discharge a pint 
or more of pus periodically; and the overflow from hydrosalpinx 
has sometimes been mistaken for hydrometra. In one of Tait's 
cases there was an extreme dryness of the middle third of the 
tongue, as in typhoid fever. Some of these patients complain 
of a peculiar pain at stool, which causes nausea and faintness. 
One woman said that when she awoke in the morning her ovaries 
awoke soon after; and another said the ovary felt as a biscuit 
might feel when a fork was stuck through it! 

But these symptoms are not very distinctive or satisfactory. 

They must be confirmed by a careful bi-manual examination. If 

the abdominal parietes are thin, and the tumor 

The objective symptoms. ^^ ^ develope(i ^ gize an( j locatio n, its 

point of attachment, mobility and texture can be pretty clearly 
distinguished. But the difficulty and sometimes the impossibility 
of making an accurate diagnosis by any kind of physical exami- 
nation is quite pronounced. Such patients are so nervous and 
apprehensive, and the sensations elicited are so misleading and 
deceptive that it is better to give them an ansesthetic before 
making such an examination. 

The signs elicited vary greatly. Sometimes one lateral cul-de- 
sac is free and the other is not; the uterus is more or less 
enlarged, retroflexed, with limited mobility ; the 
The physical signs. outline of the tumor? if there is one, is irregu- 
lar, sometimes fluctuating, again firm to the touch, partially fixed, 
and likely to be matted with a mass of peritoneal adhesions. The 
cyst-wall is occasionally so thin and flaccid as to escape detection 
by the bi-manual touch ; and in very rare cases not only the 
bladder, but the corresponding ureter also may be involved to the 
extent of inducing an ascending uretero-pyelitis. In case of 
emaciation involving the abdominal parietes the corded, sacculated 
or dilated oviduct can sometimes be plainly felt lying at right 
angles to the uterus, but this is exceptional. Since a share of 
these tumors have been caused by some local injury physical 



DISEASES OF THE UTEKINE APPENDAGES. 1023 

exploration is more readily directed to the seat of the lesion; and 
we must not forget that these tubo-ovarian formations are some- 
times developed in a latent and unsuspected way like cold 
abscesses. 

A serious drawback to a clear and satisfactory diagnosis 

almost always exists in the impossibility of obtaining a correct 

idea of the early history of the case in hand. 

diagSosfs inselements ° f I£ the lesion dates from child-birth, there is 
not one patient in a thousand who can give us 
any definite information concerning the affection from which she 
suffered during her lying-in. We know that the tubes may be- 
come the seat of inflammation by an extension of the disease 
from the cavity of the puerperal uterus (metro-salpingitis), and 
that it rarely, if ever, happens that the disease encroaches upon 
those tubes from the peritoneal side; but this knowledge is far 
from being definite. If the mischief is the sequel of abortion 
the causative details are not always available; and, if it is from 
gonorrhceal infection, the poor victim either does not know it, or 
she will refuse to testify to all the facts in the case. Tait cites a 
case in which a woman refused for six years to confess that she 
had had an attack of acute gonorrhoea which she contracted 
from her husband. 

In doubtful cases the exploratory incision is the final appeal. I 
have already (Lecture LVIII. ) given you detailed instructions as 

to the value of the abdominal section as a diag- 
otom?!° ratlve lapar " nostic resource. You have seen it made in my 

clinic, and you therefore know that it is too 
serious a measure to be lightly regarded, or practised without 
the utmost care and precaution. Prof. Wylie says: "The oper- 
ation for the removal of the appendages should be done only in 
very extreme bed-ridden cases, after a prolonged and careful 
trial of other means of cure by more than one doctor." I would 
place the same restrictions upon a resort to laparotomy in order 
to settle the diagnosis. Otherwise we might be tempted to open 
the peritoneum for the cure of dysmenorrhcea, or sterility, when 
the surgical treatment of spasm, flexure, or stenosis of the uterine 
cervix is all that is necessary to cure the case; or, Emmet's oper- 
ation might dispose of a lesion that was responsible for all the 
symptoms, whether local or reflex. In such cases it would be 
wrong and unwarrantable to take the risk of abdominal section 
when the lesion was not peri-uterine, and the resources of perito- 
neal surgery were decidedly contra-indicated. 

As to the removal of the diseased appendages, there are cases 



1024 THE DISEASES OF WOMEN. 

in which surgery may rightly intervene, but I am persuaded that 
these cases are not so very frequent as the 
made?* to ° frequently prevalent zeal for operating might lead you to 
suppose. And this opinion is not merely 
theoretical. Ten days ago a woman of thirty came into my office 
and said that she was a milliner in a neighboring town. Being 
in the city "on business," and not fee] ing very well she had con- 
sulted a physician, who had startled her by the statement that 
the only cure for her case was to "take out both her ovaries!" 
And yet she assured me that for years she had not lost more than 
one day in each month from her duties on account of ill health. 
In recent times it is not an uncommon thing for women to get a 
notion, one way or another, that these organs should be removed 
and that all the doctors are ready and capable for this kind of 
service ! 

"It is not that this operation is being too much done, but it is 
being done by too many men. The trouble in this country is, 
that too many men think they are competent to open the abdo- 
men and decide what there is there as well as those who have 
learned what they know from a large hospital and clinical expe- 
rience. Let us put the blame where it belongs." — (Stansbury 
Sutton. ) 

While, under the proper circumstances, no operation is more 

promotive of good than this, I know of no more difficult question 

than to decide upon its advisability where an 

The serious nature of . -iijt i £ i i • • *ii 

absolute diagnosis beiorenand is impossible. 
Even the most experienced gynecologist will sometimes be forced 
to depend upon a preliminary laparotomy, which may be followed 
by the removal of the whole or a portion of the uterine appendages 
if it is best. In all cases, however, since the curative result is 
doubtful, and the operation is a dangerous one, the patient and 
her family should be made acquainted with the facts in the case, 
before the knife is taken in hand. When extirpation of the 
diseased structures is plainly a matter of necessity and not of 
choice we should proceed with the same precautions as for an. 
ovariotomy. 

Before describing the different methods of operating I must 
caution you against perpetrating a scandal and a slander upon 

all reputable gynecologists by the use of the 
''s?ayhi g^ tomy is not word "spaying," as applied to the removal 

of the ovaries and their appendages in women. 
The spaying of females among animals, as you very well know, 
is resorted to for the purpose of fattening them, and to prevent 
procreation, and for no other reason. No honorable gynecologist 



DISEASES OF THE UTERINE APPENDAGES. 1025 

has ever proposed or practised oophorectomy in women with 
these objects in view. It is a surgical resource that is always 
and invariably designed for the removal of diseased structures, 
which are directly and decidedly mischievous, and which, by 
involving and complicating the menstrual and nervous functions, 
give origin to chronic disease and invaUdism. The indications 
for it may not always be very clear and definite, and it may some- 
times lie within the domain of doubtful surgery, but, in decent 
hands, it never will deserve so unkind an epithet.* 

BATTEY'S OR HEGAR'S OPERATION.-OOPHORECTOMY. 

This operation which was first made by both Hegar arid Battey 
in 1872 independently of each other, consists in the removal of one 

or both the ovaries for the cure of local, inci- 
adapS. to wMch lt is dental, or reflex disorders. The cases to which 

it is adapted are the intractable menorrhagia 
that is incident to uterine fibroids, in which it acts by precipitating 
the menopause ; epileptiform hysteria, especially if it is of trau- 
matic origin, with displacement of the ovary (obphoro-epilepsy), 
as in some of the cases which you have seen in my clinic; reflex 
insanity (oophoro-mania) where the trouble recurs, or is greatly 
aggravated at the month (menstro-mania) ; and an otherwise 
incurable ovarian dysmenorrhea. It is not suited to nympho- 
mania, nor is it necessary in disorders of a purely hysterical kind. 
In rare cases as in atrocious ovarian neuralgia, even when the 
ovary itself is not organically diseased, it may be the source and 
the center of reflex mischief that is incurable by any other means. 
Dr. Battey' s most recent statement of the indications for this 
operation are as follows: "The circumstances under which I 

would remove the ovaries are (1) where the 

Indications for. -. -, i j-i • i i i " i i • 

general health is broken down by disease, 
where there is no reasonable expectation of restoration by any 
other known means, and where I think there is reasonable pros- 
pect of restoration by a loss of the ovaries. (2.) The patient 
must be utterly miserable. (3.) It must appear that there is no 
other practicable remedy. (4.) It must appear probable that 
the operation will eventuate in a cure." (Trans. Am. Gyneco- 
logical Society, 1886, page 114.) 

Now, that the removal of sub-serous fibroids of the uterus 

*The word "spaying" is eminently objectionable, for it is entirely misleading. Whenever 
used it at once conjures up the idea of masculine voice, the growth of a beard and other male 
peculiarities, as well as the loss of sexual appetite, not one of which is an incident in the 
complete after-history of a case of the removal of the diseased uterine appendages from a mature 
woman. It is a term, therefore, which ought not be nsed, as well for the other reason, which 
you so trenchantly pointed out, that it is one of reproach to the poor sufferers who have had 
to submit to it. (Cor. of Lawson Tait.) 



1026 



THE DISEASES OF WOMEN. 



In uterine fibroids. 



through abdominal section (laparo-myomotomy), and of the uterus 
also (laparo-hysterectomy) is practised by our 
specialists with increased safety and success, 
the extirpation of the ovaries in order to control an incidental 
menorrhagia is not so commonly resorted to as it was a very few 
years ago. And experience has taught us that too much was 
expected of this operation when it was made for the relief of 
obscure reflex disorders of the nervous system without care and 
discrimination. We are learning that it fails of a radical result 
if the nervous lesion is not centered in the in- 
ternal generative organs, of which the ovary is 
the chief. You will recall the fact that I have promised very 
little in these cases before the operation was begun, because it 



In nervous affections. 




Fig. 189. Diseased ovary and tube. (Terrillon.) 

was impossible to say whether the ovary was primarily and chiefly 
at fault. And in old neurotic subjects it may happen that 
secondary lesions of the nerve-centres have become so fully 
developed as the result of chronic ovarian disease, that the removal 
of the original thorn in the flesh will not cure the case. What- 
ever the condition, and however strong the indications for Battey's 
operation, you should remember that the nervous symptoms 
especially will be slow to leave and to yield, and that possibly the 
cure will be delayed for a year or more. Nor should you forget 
that a section of the peritoneum will bring you face to face with 
the organic lesion, if there is one, and not leave you to guess at 
the import of symptomatic indications of the most unsatisfactory 
kind. 



DISEASES OE THE UTERINE APPENDAGES. 



1027 



In mania. 



The forms of mania that depend upon sexual causes are so 
varied, and often of so transient a character, that this operation 

is not always advisable, even when the ovaries 

are in a high state of irritation and of chronic 
disease. I have repeatedly seen cases of mental aberration and 
nerve-storm in which one would be tempted to remove the ovaries, 
but which have proved to be self-limited, and have finally gotten 
well without it. In some of them the fault was with the hus- 
band, and if any operation was justifiable, he should have been 
the subject. The real point of difficulty is to decide what forms 
of neurotic disease are most likely to be improved or cured by 
this operation. 

It is important to bear in mind that isolated and uncompli- 
cated disease of the ovaries is the exception and not the rule ; 

for it rarely happens that the corresponding ovi- 
wi?k^h7 a ivary. the tube duets are not also involved in the morbid process. 

(Fig. 189. ) The result is that the extirpation of 
the ovaries alone is not always sufficient. One or another of the 




Fig. 190. Pyosalpinx with adherent ovary. (Terrillon.) 

forms of salpingitis already described almost always complicates 
the case, and it would not be either safe or expedient to leave a 
diseased tube behind. Sometimes these organs are so closely 
united through adhesive inflammation that it is impossible to 
separate them. (Fig. 190.) 

The possible recurrence of the menses after the removal of both 
ovaries is a serious objection to the performance of Battey's 

operation for the cure of menorrhagia, and of 
*i^StSti^ f oSSS^ other forms of pernicious menstruation. Such 

a result is attributable to the leaving behind of 
a shred of the ovarian stroma, to the location of ova-bearing 



1028 THE DISEASES OF WOMEN. 

tissue between the folds of the peritoneum, or to the possible 
existence of a third ovary, which has not been disturbed by the 
operation.* Still another cause for this kind of failure is the 
non-removal of the tubes, which doubtless play an important 
part in the monthly function. Several of my cases after recover- 
ing from an ovariotomy, have continued to menstruate, but irreg- 
ularly, through the pedicle which had been treated by the clamp. 
Instances have been reported, in which the pedicle having been 
tied and the ovaries left in situ, as advised by Simpson in 1879, 
menstruation not only recurred, but pregnancy actually took 
place. It is quite probable that bistournaqe, or 

Bistournage, etc. r, •, , , . ■*■ . . x » ,, .„ ., iii 

the double torsion or the ovary, it it could be 
practised in women, would be followed by the same result. The 
crushing of the ovaries in lieu of their extirpation is a barbarous 
expedient that is never justifiable. 

In detail this operation does not differ essentially from salp- 
ingotomy, or the removal of the tubes, with which it is usually 
conjoined, and of which we shall speak presently. Oophorectomy 
may be made either by the abdominal or the vaginal method. In 
the great majority of cases the former is the easier and the safer 
method. The indications for extirpation of the ovaries per 
vaginam are substantially those which have already been given 
for vaginal ovariotomy. (Lecture LXI.) 



This operation is designed for the removal of the diseased tubes. 
Until it was made and had been frequently practised the physiol- 
ogy of the oviducts, as they are related to the 
ows h tothifo C p^on. ce Unction of menstruation, was not fully under- 
stood. And prior to that time the profession 
was almost equally in the dark concerning the pathology of this 
portion of the generative intestine. It was left for the knife o£ 
the gynecologist of our own day to direct the professional atten- 
tion to these very important subjects, and to develop this special 
section of clinical surgery. 

As already stated, the co-existence of tubal and ovarian disease 
usually necessitates the performance of both the operations under 
review. The Battey-Tait operation, or the 
ticSf Battey " Tait opera ~ Eemoval of the Uterine Appendages, is indicated 
under the conditions with which you have just 
been made familiar, and it only remains to detail the steps by 
which it should be accomplished. 

*Weigel examined the bodies of six hundred women, of whom he found that twenty- three 
had more than two ovaries. 



DISEASES OF THE UTERINE APPENDAGES. 



1029 



The preliminaries are the same as for an ordinary ovariotomy. 
(Lecture LIX. ) The strictest surgical cleanliness of the hands, 
clothing, instruments, sponges, and the assistants, is indispensable. 
The incision should be made in the mesian line and need only be long 
enough for the admission of two, or at the most of three fingers. It 
can afterwards be enlarged if necessary. If the 

The different steps of . , , . , ,, . *?, . -, .. . , ,~ . . 

abdominal wall is very thick, it is better to put 
a loop of aseptic silk through all the tissues midway of each lip 
of the wound so that its margins can be retracted if necessary, 
and in order to avoid trouble in finding the peritoneum when the 
incision is to be closed. When the haemorrhage from the wound 




Fig. 191. Haematic cyst of the ovary with pyosalpinx. (Terrillon.) 

lias been controlled, the peritoneum is opened, any parietal ad- 
hesions are carefully separated, and the clean fingers of the oper- 
ator are passed to the fundus of the womb, whence they glide 
along the Fallopian tube to note its size, form, and relations, and 
finally, to the ovary. If we encounter a cyst, or a fluctuating 
tumor the probability that its wall will be fragile, and that it 
might be ruptured by the necessary manipulation is so great 
that it had better be carefully tapped and its contents removed. 
This can be done by such a small aspirator as you saw me use 



1030 THE DISEASES OF WOMEN. 

for this purpose a few days ago, and will prevent the mischievous 
discharge of the poisonous fluid into the peritoneal cavity. 

If only one side is affected, and the uterus is not retroverted, 
the lesion of the tubes and of the ovaries, if both are involved, 

can be readily identified. Moreover, such a 
dangers^ 111 ^ 8 and case is pretty easily managed, for, if there are 

no complicating adhesions, the tumor can be 
speedily drawn to the lower angle of the wound and disposed of. 
But, suppose you find a double pyosalpinx, or that a prolapsed 
tube is adherent to the sigmoid flexure, with a chronic uterine 
displacement, or there is a hernia of one or of both the ovaries, 
with adhesions on all sides, more especially in the Douglas 
pouch ? In this case the ligaments and the tubes are rolled up, 
and the ovary is so imbedded in a mass of tissue that you can 
scarcely identify it, much less detach it and bring it away with 
safety to the patient. This is the especial point of difficulty and 




Fig. 192. Pean's long haemostatic forceps. 

of danger ; and, although we read and hear of these organs being 
plucked out in the space of ixve or ten minutes, it will be safer 
for your patients and mine if we shall hasten a little more 
slowly. 

With hydrosalpinx the adhesions are not likely to be so firm 

and vascular as they are in pyo- and hsemato-salpinx. Classes 

6 and 7 will not soon forget the varicose en- 

The adhesions in. , . * . n . . «° , . n 

largement or the pampiniform vessels in the 
right broad ligament which they saw in our last operation of this 
kind. That was a condition in which a little rough handling 
and despatch might easily have induced a fearful, if not a fatal 
haemorrhage. 

When the dilated and degenerated organs have finally been 
brought to light they may be secured with Pean's haemostatic 
forceps (Fig. 192), or some similar instrument, and afterwards 
tied with a Staffordshire knot. The double ligature that is inter- 
locked and tied both ways answers equally well. Some operators 
think it safer to put a second ligature about the pedicle en masse. 



DISEASES OF THE UTERINE APPENDAGES. 1031 

The haemorrhage must be guarded against, and before the 
pedicle is dropped into the abdomen again it should be carefully 
dried. My own practise is to cauterize the stump the same as 
in ovariotomy. If the second ovary and tube are in the slightest 
degree diseased they also should be removed. The operation of 
extirpating the tube with the ovary gives a better pedicle and 
therefore better results than if only the ovary is taken. 

The shreds of adhesions and the denuded edges and surfaces of 

the omentum especially are very apt to bleed freely. Should 

haemorrhage occur from this source a few catgut 

Haemorrhage and drainage, t , ° -. -i» .li i i 

ligatures may be necessary, or it there has been 
an accidental rupture with the discharge of the cyst contents into 
the peritoneal cavity, boiled and filtered water at a temperature 
of 102° to 105° may be poured into the abdomen to stop the flow 
and to cleanse it thoroughly. The question of drainage is easily 
settled. The more extensive the adhesions, and the greater the 
probability of a copious effusion of bloody serum from the torn 
surfaces, the greater the need of the glass tube as a prophylactic 
of sepsis. Where there has been an ascitic accumulation there is 
an especial indication for drainage. The tube should afterward 
be taken care of as in ovariotomy. 

The wound should be carefully cleansed before it is closed, and 

the deep sutures passed first in order, after which I think it is 

' better to stitch the peritoneum separately with 

Closure of the wound. ., .. . ■*• . . i o n 1 1 

the continuous catgut suture before the others 
are tied or twisted. The dressings should be dry and antiseptic, 
and the after-treatment essentially the same as was recommended 
in Lecture LX. 



LECTURE LXIII. 

FIBROID TUMORS OF THE UTERUS. 

Uterine fibroids. Their relative frequency, pathological anatomy, number, weight, tex- 
ture and varieties. 1. Sub-mucous fibroids. Symptoms. The hsemorrhage, uterine 
deviations, the uterine souffle, tolerance o"' the tumor, hi- manual examination. 
Causes. Diagnosis from ovarian dropsy, piegnancy. hydatids, and uterine versions. 
Prognosis. Treatment, medical, palliative and surgical. 2. Sub-peritoneal fibroids. 
Symptoms. Co-incident disorders. Diagnosis. Course and termination. Treatment, 
medical and surgical. Hysterectomyo 

A course of lectures on our speciality would be very incom- 
plete without some remarks upon the clinical history and treat- 
ment of uterine fibroids. This is true not only because of the 
interest which attaches to neoplastic growths in general, but 
especially because those which are uterine are more readily diag- 
nosticated and cured than they were a few years ago. 

These tumors which, according to various authors are found in 

from 20 to 40 per cent, of those women who are ill with uterine 

disease after their thirty-fifth year, are benign 

Relative frequency. , ,. AT , , , 

and not malignant. JNor do they ever degen- 
erate into cancer, or any other form of malignant growth. This 
fact is interesting in a prognostic point of view, and also with 
respect to their cause and mode of development. 

I need not remind you that the fibrous and cellular structures 

of the uterine wall exist in a rudimentary state until they are 

especially developed in consequence of concep- 

Pathological anatomy. . . . ' 

tion, or ot growth within the uterine cavity or 
a foreign body of some kind. The possibility of this extraor- 
dinary increase necessitates such changes in the circulation to 
and through the organ as will supply sufficient nutritive material 
therefor. It is because the depth and dimensions of the uterus 
may be so much increased, in consequence of a phvsiological 
stimulus, that these fibroids are formed. In all essential particu- 
lars, their growth and development is identical with that which 
takes place in the muscular coat of the womb during pregnancy. 
The only difference i^ that in fibroids the actual increase in the 
substance of the uterus is circumscribed, instead of being general ; 
and that it is pathological and more or less permanent, instead of 

1C32. 




FIBROID TUMORS OF THE UTERUS. 1033 

"being physiological and of limited duration, as it is in pregnancy. 

Unless they have undergone some form of benign degeneration, 

fibroids are therefore homologous and not heterologous. There 

is indeed a new growth of tissue, but it is of 

Homologous growths. 

the nature ol a local hypertrophy, and, except- 
ing in a mechanical way, is not foreign to the part affected. 
Sometimes these tumors consist exclusively of a prematurely de- 
veloped muscular fibre, constituting veritable myomata, but in 
most cases the connective tissue is also involved, and hence it has 
been customary to style them myo-fibromata. Microscopically 
considered, there is nothing distinctive in these growths, except- 
ing perhaps, that the arrangement of their fibres is more irregu- 
lar, w^avy and tortuous than in the proper uterine tissue. 

These tumors are either single or multiple. There may be 
but one of them ; there have been as many as forty within and 

upon the same womb. They generally assume 
te^ur^' weight and a rounded form at first, and afterwards change 

their shape, according to circumstances. They 
may remain sessile, but are more apt to become pedunculated. 
Their size varies from that of a marble to a man's head, or even 
larger. They may weigh an ounce, or as much as twenty, thirty, 
fifty, or even a hundred pounds. Their solidity varies with 
their location and vascularity, the rapidity of their growth, and 
their tendency to undergo cystic, carneous, calcareous, or fatty 
degeneration. The more strictly fibrous the tumor, the more suc- 
culent it is. 

There are three varieties of uterine fibroids which are named 

from their location with reference to the cavi- 

V3.ri*ctics 

ties of the womb and of the abdomen, and also 
to the uterine wall. I will speak of them separately. 



I. — SUB-MUCOUS FIBROIDS. 

As their name implies, these tumors are situated directly be- 
neath the endometrium, or lining membrane of the womb. They 
are really contained within the uterine cavity, 

Sessile or pedunculated. p i i i • 

and hence are irequentiy styled mtra-uterme. 
Their mode of development appears to be as follows : From some 
cause, which may be known or unknown, the fibro-cellular tissue 



1034 



THE DISEASES OF WOMEN. 



of the uterus becomes thickened, and of increased vascularity at 
a particular point. This growth, nodule, or hypertrophy, con- 
tinues to increase in size, perhaps for months, or even for years, 
without any untoward symptoms. Being located in closer prox- 
imity with the mucus than with the peritoneal coat of the organ, 
it pushes in that direction, and finally invades the uterine cavity. 
Here it may continue to grow in all directions as a round tumor, 
with a broad base, which gradually fills the womb; or it may be- 
come pear-shaped, and finally develop into a fihrous polyp, with a 
neck or stalk which is sufficiently long and slender to allow it to 
drop into the os internum, or even into the vagina. As in ova- 
rian tumors and polypi, the pedicle is the means of . keeping up 
the vascular connection with the uterus. (Fig. 193;. 




Fig. 193. A sub-mucoua fibroid. 

Symptoms. — The symptoms indicative of the presence of such 
a tumor are objective and subjective. The patient complains of 
a sense of w eight and dragging down, intra-pelvic pains and dis- 
tress, lumbo-abclominal aching, vesical or rectal tenesmus, inabil- 
ity to walk without great dread of procidentia of the pelvic organs, 
uterine colic, pains in lying upon one side or the other, sick head- 
ache, nausea, morning sickness as in pregnancy, copious and 
sometimes very painful menstruation ; the catamenia are too fre- 
quent as well as menorrhagic ; weakness, prostration, constipation 
and unrest. Of course these symptoms vary in different cases,. 
and also with the size and shape of the tumor or tumors. The 
larger the tumor the oreater the coincident suffering. Pedicu- 



FIBKOID TUMORS OF THE UTERUS. 



1035 



latecl fibroids are, in general, more likely to excite strong uterine 
contractions than those which are sessile. Indeed, there is a 
theory that, in some cases, the force of the peristaltic contrac- 
tions of the womb, or the uterine tenesmus, is the cause ot this 
particular form of the tumor, and that these bear a constant 
relation to each other. My own observations confirm the truth 
of this theory. There are, however, some exceptions to the rule. 
Other forms of uterine fibroid may also excite contractions- 
that resemble those of labor ; and hence this symptom does not 
belong especially to those growths which are contained within the 







Fig. 191. A sub-peritoneal fibroid. 

body of the womb. Here is a drawing (Fig. 194), in which the- 
fibrous growth is attached to the fundus of the uterus externally, 
and you can readily see that it might be the cause of pains like 
those of labor, although there is nothing to be expelled from the 
uterine cavity. However, the rule is that sub-mucous fibroids 
are more likely to be accompanied by labor-like pains than are 
either of the other varieties of uterine fibroids. 

The most alarming and constant of these symptoms is the 
haemorrhage which, however, is a menstrual flux. Seventy 
per cent, of intra-uterine fibroids are accom- 
panied by haemorrhage. The flow, which is 
very free, is usually, but not always painful, and very debilitating, 
If it has continued long, the patient becomes anaemic, bloodless, 
and perhaps dropsical also. It returns every fortnight, or three 



1036 THE DISEASES OF WOMEN. 

weeks ; she does not recover from one attack before another is 
upon her. It is astonishing how small a fibroid may serve to per- 
petuate such a haemorrhage. For it may happen that a little 
body of this sort, which is not larger than a grape, may cause as 
great a loss of blood as sometimes does the fragment of placenta 
which is left in the womb after an abortion. Leucorrhcea, serous 
discharges and obstructive dysmenorrhcea are often due to the 
presence of uterine fibroids. More rarely the tumor blocks up 
the outlet, and there is complete retention of the menses. 

Incidental symptoms of uterine deviation are always present. 
The larger the tumor the greater the displacement. Being at- 
tached more frequently to the posterior wall of 

Uterine displacements. 

the womb, retroversion and retroflexion are very 
common. If, however, as sometimes happens, the point of attach- 
ment is to the fundus, and the tumor is a very large one, the organ 
may be inverted. Ante version, anteflexion and prolapsus are not 
infrequent. Latero-version, a state of things in which the body of 
the womb is forced towards one side of the pelvic basin, is some- 
times caused by the presence of an infra-uterine fibroid. 

Beside the morning sickness, anorexia and caprices of appetite, 
the development of the mammary glands, of the areolae, and of the 

abdomen, there are other signs simulating 

Changes in the cervix. i i i 

those of pregnancy, that are caused by the 
growth of a fibroid in utero. The cervix is shortened, and may 
become flaccid and patulous. More frequently, however, after some 
months, it forms a ring which is resistant and sometimes very sen- 
sitive to the touch. Auscultation through the abdominal pari- 

etes (providing the tumor has passed above the 

The uterine souffle. . . 1 • 1 

pelvic brim) reveals the uterine souffle, which 
you remember was once regarded as a positive sign of pregnancy. 
In exceptional cases there is a singular tolerance of the pres- 
ence of these tumors. Some women carry them for years and 

become so accustomed to them that they make 

Tolerance of the tumor. . pi ,, . -, 

very little if any complaint of them. It is only 
in consequence of the haemorrhage, or the pressure they occasion, 
that they are led to take measures for their removal. They do 
not always interfere with pregnancy, although they grow more 
rapidly in the gravid than in the non-gravid uterus. They some- 
times cause abortion. 



FIBROID TUMOES OF THE UTERUS. 1037 

These tumors, as they grow, lead to an enlargement of the 

uterus and an increased size of its cavity. Hence, if the organ is 

not quite filled with the fibroid, the sound will 

Increased size of the uterus. , . .. , , „ , , 

pass quite readily, and perhaps iartner than you 
would have supposed. For the depth of the uterus may be as 
great as it is at term. In order to get the best idea of the size, 
and the point and mode of attachment of the growth, you should 
select a flexible sound, which will adapt itself to the contour of 
the tumor without force, and, therefore, without inducing pain 
or haemorrhage. 

As felt through the abdominal parietes, the outline of the 
tumor can usually be very well recognized. There is dullness on 
percussion over the whole anterior surface of 
the womb. It is not unusual for the patient to 
complain that one particular spot is and has always been painfuL 
and tender to the touch ; but there is no diffuse soreness. The 
uterus is hard and resistant to external palpation. 

These tumors, being invariably attached to the body and fun- 
dus of the womb, a vaginal examination by the touch is of little 
use unless the growth is large enough to be 
felt, or so to displace the uterus that it can be 
reached. In case the tumor is very large, the whole organ may 
be displaced upwards, above the brim of the pelvis and the 
" touch " reA^eal nothing. In some cases the 

Bi-manual examination. ..-..-, . 

"touch may be conjoined with pressure with 
the ,tips of the fingers of the free hand over the uterus and just 
above the pubes, as in Sims' bi-manual exploration. 

Causes. — The causes are not well known. That the growth of 
these tumors bears a certain relation to the menstrual function, 

and to that of procreation also, is evident from 

bearin nstruatI ° n and chiW ~ tne fact tnat tne J are most frequently devel- 
oped at a period when these functions are most 
active. But precisely what that relation is has not been deter- 
mined. In a certain class of cases it is probable that the fibroid is 
a sequel, or a consequence, of the incomplete involution, or fold- 
ing upon itself, of the uterus after delivery. It has happened 
that a clot has been found to form the nucleus of a uterine 
fibroid. 

Diagnosis. — The diagnosis is difficult. I have already told you 



1038 THE DISEASES OF WOMEN. 

liow to diagnosticate a case of intra-uterine fibroids from one of 
ovarian dropsy.* The hardness and mobility of 

From an ovarian cyst. 

the tumor ; the absence of fluctuation ; the 
depth of the womb, as shown oy the distance to which the sound 
will enter ; the co-existence of haemorrhage, which may be men- 
strual, but is often inter-periodic ; the pain and uterine tenesmus ; 
the uterine souffle in either groin ; the uterine displacement and 
leucorrhoea ; and the comparatively slow rate of the growth of 
these fibroids, are sufficiently characteristic. The occurrence of 
uterine fibroids and of ovarian dropsy are not very frequent in 
those who have never been pregnant. 

The incidental hemorrhage, with its tendency in most cases to 
return at or near the month with tolerable regularity ; the tardy 

and protracted growth of the tumor ; the 

absence of quickening and of the foetal heart 
sounds ; the rounded outline and hardness of the tumor as felt 
through the abdominal w T alls : the patulous state of the os uteri ; 
and the persistent displacement of the womb, are so many signs 
which will help you to differentiate this variety of uterine fibroids 
from pregnancy. The altered and peculiar shape and consistence 
of the cervix in case of placenta prgevia, would be as different 
from that which is proper to uterine fibroids, as it is from that of 
ordinary pregnancy. You should not forget that it is possible for 
a woman with any variety of uterine fibroid to become pregnant, 
although, in case of the intra-uterine variety especially, they sel- 
dom reach term without aborting. It is therefore best not to pass the 
sound in all cases indiscriminately, and without thought of the 
possible consequences. Perhaps, in a majority of cases the large 
fibroid becomes impacted in the pelvis and does not rise into the 
abdominal cavity, as the gravid uterus does, at or about the fourth 
month. 

In the case of uterine hydatids the abdominal tumor is larger, 
grows more rapidly, is characterized by smoothness, fluctuation 

and decided distention, which subsides some- 

From hydatids. , . „ , 

what with occasional discharges 01 serum and 
blood. Sometimes small portions of the mass are detached and 
extruded, from which specimens it is possible to recognize the 
nature of the growth. When there is copious or continued ha3m- 

* See page 369. 



FIBROID TUMORS OF THE UTERUS. 1039 

orrhaoe, .the diagnosis from a uterine fibroid is more difficult. In 
this case a decision can be reached by dilatation of the cervix and 
an exploration of the uterine cavity by means of the finger or the 
uterine sound. 

It is quite impossible, in most cases, to distinguish ah intra- 
uterine fibroid from a fibrous polypus, without artificial dilatation 
of the cervix and careful exploration, unless 

From fibrous polypi. ,. ™ 

the polypus is large enough, and its pedicle suni- 
ciently long to enable it to drop into the canal of the cervix, or 
into the vagina. Their differential diagnosis is, however, not a 
matter of very great importance. The only real difference 
between them is that the fibroid is enclosed in a proper capsule, 
which really disconnects it from the surrounding tissue ; while the 
polypus is a true out-growth, which is continuous with the sub- 
stance of the uterus and covered only by its lining membrane. 
These differences are not observable, however, until the growth 
has been removed. 

These fibroids have sometimes been confounded with the tumor 
formed by inversion of the womb. They have many symptoms in 

common. But inversion follows the evacuation 
w<fm b m inversion of the of the uterus. Either the woman has recently 

been delivered, in abortus or at term, or the 
organ has first been distended and developed by a contained tumor, 
and finally turned inside out during or in consequence of its deliv- 
ery. The best test between these tumors, however, is a very 
simple one. In inversion the tumor is sensitive, and if you 
stick a pin into it the patient feels it ; but not so in case of the 
fibroid. 

By means of the uterine sound or probe alone j*ou can diag- 
From retroversion and nosticate retroversion and retroflexion of the 
Tetrofiexion - uterus from a sub-mucous fibroid. 

Prognosis. — There are several sources of danger in this disease. 
The haemorrhage may drain away the strength, and so undermine 

the health as finally to destroy life. Sometimes 

May die suddenly. ■ 

such patients die very suddenly from excessive 
loss of blood. In consequence of the mechanical pressure of the 
tumor upon the pelvic viscera, or upon the ureters, serious disease 
may be caused in the bladder, the bowels, or the kidneys. The 
reflex disorders occasioned by the same cause are harassing and 



1040 THE DISEASES OF WOMEN. 

exhausting. The impairment of digestion, respiration, and espec- 
ially of the circulation are sometimes very serious. 

In some cases the symptoms are very deceptive, and give no 

reliable criterion of the gravity of the disease. Women who have 

carried these tumors about with them for years 

Symptoms deceptive. ■ i i -i • n n 

with almost no complaint, and at last nnd them- 
selves ill, are apt to drop off very suddenly ; while those who 
complain most bitterly are often in a less dangerous condition. 

The risk of operative interference is less than in either of the 
other varieties of uterine fibroids. There are two reasons for this 

fact : (1) because the tumor is more readily 

The risk of an operation. 

reached and removed, and (z) because the dan- 
ger of consequent inflammation is in proportion with the liability 
of wounding or cutting into the peritoneal surface of the womb. 
Treatment. — The treatment is medical and surgical, or pallia- 
tive and radical. Whatever contingencies beset the case must 

first be removed. The haemorrhage is the 

Medical. 

source of danger and must be controlled. For 
this purpose such remedies as ipecacuanha, china, arsenicum alb., 
hamamelis, erechthites, crocus sat., cinnamonum, tr,illium, secaie 
cor., sabina, belladonna, nitric acid, or ferrum met., may be given 
each under its appropriate indications. The suitable remedy will 
generally suffice to relieve the pain as well as the excessive 
flow. 

If the haemorrhage is copious and continuous, and it becomes 

necessary to stop it at once, in order to husband the patient's 

strength and to save her life, and internal 

Palliative. °. . ' 

remedies act slowly or fail altogether, recourse 
must be had to such local treatment as was recommended in my 
lecture on uterine haemorrhage.* You doubtless remember what 
I then said of such available expedients as cold water locally and 
by injection, ice, ice-water, pouring cold water from a height 
upon the abdomen, colpeurysis, and the tampon. In some cases 
the sponge tent makes an excellent tampon for the cervix ; and 
Palfreyf recommends to introduce the speculum, to draw down 
the anterior lip of the cervix, and then, with the uterine sound to 
pack its canal with a long and narrow strip of lint. The lint,, 
which may have been soaked in carbolized water, should be 

* See page 80. f Medical Press and Circular, Vol. VII. p, 516. 



FIBROID TUMORS OF THE UTERUS. 1041 

allowed to remain for about twenty-four hours before it is re- 
moved. 

Among- the improved methods of homeostasis , which also in- 
clude a more or less permanent exemption from the flow, there 
is no simple expedient that is more valuable 

The sponge-tent as a ^ ^ introduction ot the sponge tent. I 

haemostatic. L o 

have known it alone to prevent the retu.rn of 
the menorrhagia, and to secure a natural flow for months in suc- 
cession. 

In obstinate cases nicking, slitting, or incising the os uteri with 
a curved, blunt-pointed bistoury, a pair of scissors, or the hys- 

terotome, has also been practised with marked 

Incision of the cervix. „ 

success. VV nether these latter means are em- 
cacious because they unload the engorged vessels, or because by 
dilating the os uteri, they empty the womb of its more fluid and 
distensible contents, and thus remedy the difficulty, I am not pre- 
pared to say. But that they certainly present a valuable means 
of relief, which is always available, and which, until quite re- 
cently, was unknown, I am well assured. 

If this treatment fails to brins: the desired relief, Dr. Atlee* 

recommends to follow up the section of the os uteri with a free 

division of the capsule of the fibroid in utero. 

Dr. Atlee's operation. . . 

llns is accomplished by means ot a long- 
handled, curved and probe-pointed bistoury, which is to be passed 
into the uterus as far as the grinding finger will reach, and then 
drawn firmly down over the tumor so as to cut through its capsule 
and into its substance to the depth of half an inch. This opera- 
tion not only lessens the haemorrhage, but so impairs the nutri- 
tive vitality of the fibroid that its destructive metamorphosis is 
soon established, and it will be either enucleated spontaneously, 
or thrown off with a kind of leucorrhceal discharge. This prac- 
tice seems to me to be especially adapted to tumors with a broad 
base and margin of attachment. 

There is a certain proportion of cases of uterine fibroids, more 

especially of the sub-mucous and the intersti- 
tions P o?er™ot C mJeC ~ ^^ varieties, in which the haemorrhage can 

be controlled and the growth of the tumor 
held in check by the sub-cutaneous injection of ergot. I could cite 

^Transactions of the American Medical Association, 1858, p. 558. 



1042 THE DISEASES OF WOMEN. 

you many cases in which I have been successful by this means; 
in a few of which the growth has disappeared entirely. Occa- 
sionally there is such a susceptibility to the action of this poison 
that ergotism is readily induced, and we have to desist from its 
use. I prefer Squibbs' solution of ergot, which can be prepared 
by any responsible druggist, which ought to be fresh, and which 
contains a grain to the minim. Of this solution from three to 
six drops may be thrown into the integument in the hypogastric 
region (but not perpendicularly into the tumor), two or three 
times per week. Bartholow r 's solution also answers very well. 
A good result from the ergot is that uterine contractions which 
tend to force an interstitial fibroid into its cavity, and a sub- 
mucous fibroid into the vagina, where they are accessible, is pretty 
sure to follow. The taking of ergot by the mouth will almost 
never do any good in these cases. 

Another expedient for the control of the hemorrhage is a re- 
sort to the removal of both the ovaiies, as 

Battey's operation in. 

already described under the head ot normal 
ovariotomy. The eflect of this operation is to arrest the monthly 
flow and to precipitate the menopause. As a natural consequence 
the periodical afflux of blood to the womb is arrested and that 
organ with whatever is nourished bv its vessels undergoes the 
same atrophy as if the change of life had come about in the 
natural way. 

Very much has been claimed for electricity in the cure of these 
tumors, but I know of very little that is to be 

Electricity and elec- . " , , . 

troiysisin. relied upon in the support ot that claim. It is 

so serious a matter to puncture these growths, 
and such fearful consequences have sometimes followed their per- 
foration, that I confess to a dread of running the electrical, or 
any other kind of needle into them. Dr. Cutter puts the case 
very well when he says that galvanism is a means, but not the 
means of treatment for sub-serous uterine fibroids. 

The same authority* quotes a number of cases to show that the 
growth and development of some of these 

An animal diet in. ' , , , .„ , ,. 

fibromata may be largely it not wholly con- 
trolled by an exclusively animal diet. I have not tested this 

* Cutter : Food as a Medicine in cases of Uterine Fibroids, American Journal of Ob- 
stetrics, etc., Vol. X., page 562. 

fi2 



i 



FIBROID TUMORS OF THE UTERUS. 1043 

matter except in a ease which was brought to me by the late Dr. 
Von Tagen, in which it had no perceptible effect. 

But unless Dr. Atlee's operation shall result in the extrusion 

of the fibroid, either as a whole or in fragments ; or it shall be 

spontaneously detached and expelled, as it 

Excision of the tumor. . . 

sometimes is, by strong uterine contractions; 
or unless it shall undergo some form of degeneration, and thereby 
escape or cease to be troublesome; a radical cure will only be 
possible by its excision and removal. This is to be effected by a 

li oration of the tumor. And two obstacles are 

First obstacle- . 

in the way or its accomplishment, lhe first 
of these is the narrow state of the cervix uteri. To overcome it 
we must resort to free dilatation. If the tumor is quite large, 
and the cervix is shortened and softened, as in the later months 
of pregnancy, two or three sponge tents of various sizes may be 
introduced successively. These will expand the neck so that the 
fingers can be passed within the womb, the exact site of the 
tumor ascertained, its mode of attachment also, and the instru- 
ment adjusted. For this must be done by the sense of touch, 
and not by sight. 

In the more rigid and unyielding states of the cervix, the sea- 
tangle tents are preferable. Ot these quite a number are to be 
passed through the internal os uteri one after 

Dilatation the fii st step. \ . n . 

another, until it contains iro-m three to seven 
or eight of them. The longer these tents are the better. They 
sliould be allowed to remain for from twelve to twenty-four hours. 
On their removal, it the dilatation is not sufficient, one of Barnes' 
rubber dilators may be inserted through the cervical canal, in- 
flated, and left in situ tor some hours longer. These expedients 
will provide a mode of entrance that will make the further steps 
of the operation possible. To secure a free expansion of the cer- 
vix, it may perhaps be necessary to incise it at the same time that 
you dilate it. 

The second obstacle in the way of operating in some of these 
cases is the difficulty of adjusting the ligature, or rather, the 

chain or wire of the ecraseur. If the tumor is 

The second obstacle. , , . . , ... 

m the vagina, and is not very large, there will 
be no trouble in this respect; but if it is in the uterus, and more 
than all, if it is attached to the fundus, and has a broad base, in- 



1044 



THE DISEASES OF WOMEN. 



stead of a pedicle, you will find that it is not so easily done as 
you might have supposed. Indeed, it may require repeated trials 




Fig. 195. Greenhalgh's tumor forceps. 

before you succeed in carrying the loop of the ligature over and 
beyond the tumor. A few authors insist that, to facilitate this 




Fig. 196. Sims' volsellum hook. 

object, the uterus should be dragged down to the vulva. But, 
unless in very exceptional cases, this proceeding is barbarous and 
unnecessary. See case given on page 893. 




Fig. 197. Steele's volsellum forceps. 

It is quite a different thing however, to sieze the tumor and 
draw it down. This expedient is so necessary in most cases that 
a volsellum of some kind should be at hand, and it is best to be 




Fig. 198. Byrne's volsellum forceps. 

provided with two or three of them. Greenhalgh's tumor forceps 
(Fig. 195), Sims' volsellum hook (Fig. 196), Steele's (Fig. 197), 



FIBROID TUMORS OF THE UTERUS. 



1045 



or Byrne's volsellum forceps (Fig. 198), or the simpler tenaculae 
(Figs. 199, 200) are excellent in suitable cases. 

This manipulation, if successfully made, facilitates the adjust- 
ment ol the ecraseur, with which we intend to excise the tumor. 




Fig. 199. A volsellum forceps. 

And here again there is a choice of instruments. The texture of 
the orowth is so firm that a delicate instrument would soon be 




Fig. 200. The old volsellum. 

"broken ; and therefore the ecraseur must be strong enough for 
the purpose. If the tumor is really within the uterine cavity the 
instrument should not have a straight shank, as in (Fig. 201), but 
.should be curved like the uterine sound, (Fig. 202). 




Fig. 201. A straight ecraseur. 

Whether the ecraseur shall carry a wire or a chain, or if they 
shall be united as in Thompson's instrument, (Fig. 203), will de- 
pend upon circumstances. Braxton Hicks' wire-rope, as well as 
the copper wire, are apt to get into a snarl, or to break from a 
strain. In two ot my operations the strongest copper wire that 
I could find broke when the tumor was about half cut through. 
If you can succeed in adjusting the chain, I think you will feel 
most confident of a o-ood result. 



1046 



THE DISEASES OF WOMEN. 



Ill order to ensnare the tumor most readily, let me give you a 
hint which I have found of great service. First ascertain as 
accurately as possible the precise site of the 
tumor, and its point of attachment to the uterine 
wall. Then place the patient in such a position that it will drop 



A practical hint. 




Fig. 202. Tiemann's chain ecraseur. 

away from its pedicle, or base, towards the opposite side of the 
womb. If it happens to be centrally located the position of the 
patient is less important. Fortunately a majority of these intra- 
uterine fibroids, and fibrous polypi also, grow from the posterior 
wall of the womb ; and therefore the patient is usually placed in 
what is now known as the left lateral position. 

When the instrument is finally adjusted, all that remains is to 
tighten it slowly and steadily until the tumor is cut off. This 
should be done very gradually, lest the wire 
break. Iron wire will not stand the strain; but 
the wire-rope or steel wire are more trustworthy. If the tumor 



Cauton. 




Fig. 203. Thompson's ecraseur. 

is a very large one, it may need to be delivered with the obstetric 
or other forceps, or perhaps to be cut into pieces before it can be 
brought away through the os uteri. Fortunately, in ecrasement, 
there is an exemption both from immediate haemorrhage and from 
the danger of subsequent inflammation. 

In rare cases, where the tumor is very large and pedunculated, 
and occupies the vagina, it is so difficult to excise it in the ordi- 



FIBROID TUMORS OF THE UTERUS. 1047 

nary way, that it has been recommended first to seize it with the 
obstetric forceps, and then to draw it out at the 

An exceptional case. 

vulva, after which the ecraseur may be applied. 
This operation causes a temporary inversion of the womb ; but 




Fig. 204. Sims' enucleator. 

the os having been stretched so widely by the tumor, and para- 
lyzed by pressure upon it, is not likely to contract so firmly as 
to interfere with the reposition of the organ afterwards. If there 
is much haemorrhage, the stump, or pedicle, may be seared with 
an iron at a white heat, or painted with the per-chloride of iron, 
before the uterus is replaced. 




Fig. 205. Sims' blunt hook enucleator. 

When the intra-uterine fibroid is attached by a broad base, its 
removal mudt be affected in a different way. The old plan was 
to make a deep gash into the tumor and then to insert a wad of 
cotton which had been dipped in oil, or a bit of caustic, and leave 




BOP 

Fig. 206. Clark's tooth-edged scissors. 

it there so as to induce a slough. Another method consisted in 
seizing the growth with a forceps and twisting and tearing it 
forcibly out of its bed; this was called the process of avulsion, 
and is discarded now. 

Since many if not all of these sessile fibroids are encapsuled, Dr. 
Sims and others have practised their enucleation. After cutting 
through the investing tunic, a Sims' enucleator (Fig. 204), or his 
blunt hook (Fig. 205), may be introduced, and by careful and 
foible manipulation the tumor may be rolled out of its bed. 



1048 the DISEASES OF WOMEN. 

In exceptional cases, according to Dr. Emmet, the tumor will 
cause the uterus to expel it in imitation of labor; and this pro- 
cess may be aided by cutting off the accessible portions, either 
with a curved scissors, or with a pair of tooth-edged scissors like 
these, (Fig. 206). 




Fig. 207. Thomas' spoon-saw. 

Dr. Thomas' method consists in seizing the tumor at its most 
dependent and accessible point with strong volsellum forceps, 
passing up along its sides the spoon-saw or serrated scoop depicted 
in Fig. 207, and by a gentle, pendulum motion from side to side 
sawing through the attachments of the tumor and freeing it en- 
tirely from its connections with the uterus." He says: 

"The advantages which experience teaches me attach to this 
instrument are the following: (1) the attachments of the tumor 
are separated by a saw, which greatly limits haemorrhage; (2) 
the slope of the spoon, convex without and concave within, causes 
it to follow of itself the contour of the tumor unless this be very 
lobulated, and protect the enveloping tissues from injury; (3) the 
highest points of attachment of the tumor are as readily reached 
as the lowest, the freed growth descending under traction as the 
saw severs its adhesions in successive sweeps around it; (4) the 
saw action gives to the process of separation, whether the growth 
be interstitial or submucous, sessile or pediculated, rapidity or 
certainty; and (5) and last, though by no means least, the nature 
of the spoon-saw secures separation of a growth at the highest 
point of its attachment, leaving no peduncle to decompose." 

II. SUB-PERITONEAL FIBROIDS. 

These growths, which are located on the exterior surface of the 

womb, and beneath the peritoneum, are also know as sub-serous, 

extra-mural and extra-uterine fibroids. They 

Frequency, number, legg f requent than eitner f the other Vari- 

size. etc. x 

eties, but when they do exist, are almost always 
multiple. They grow more rapidly, are of various sizes, and may 
be very numerous. Not unfrequently the abdomen will be filled 



SUB-PEEITONEAL FIBROIDS. 1049 

with one which is very iar«:e, while the exterior of the uterus is 
studded with a number of smaller ones that are undeveloped. 
Sometimes, however, two or more of these tumors may grow 
together and not differ materially in their size and form. 

SymjJtoms. — Since they have no necessary connection with the 
cavity of the uterus, neither with its mucous membrane, nor 
indeed with the generative intestine in any way, the disorders of 
menstruation which are almost invariably present in the case of 
sub-mucous fibroids, are lacking in the sub-peritoneal variety. 
There is no especial liability to haemorrhage, or to serous dis- 
charges from the uterine cavity. 

The haemorrhage that accompanies this form of fibroids is in 
proportion with the breadth of the attachment of the tumor. 
The longer and more narrow the pedicle the more decided is the 
exemption from menorrhagia. It is because these sub-peritoneal 
tumors usually begin as sessile growths and gradually become 
pedunculated that the monthly haemorrhage in these cases is apt 
to diminish and finally disappear as time goes on. When this 
symptom continues, in case the tumor has a slender neck and is 
freely movable, then there may be good reason to suspect that 
other growths of the same kind have begun to develop upon the 
surface of the uterus. Here is a wet specimen in which you will 
find that there are thirteen of these extra-uterine fibroids of 
various sizes, with a varying breadth of attachment, upon a single 
uterus. 

The symptoms are, however, chiefly mechanical. Small tumors 

of this kind occasion very little inconvenience, and may exist for 

years without symptoms. Larger ones drop 

Chiefly mechanical. J ■ . / . r ? * 

into the retro-uterine space, against the bladder 
anteriorly, or press laterally in such a way as to cause pain with- 
in the pelvis or in the corresponding hip and thigh. If it becomes 
pedunculated, as it frequently does, the length of the pedicle may 
permit the tumor to float, as it were, and to change its position 
with reference to the pelvic organs, so as not permanently to dis- 
place the uterus. But, when there is no pedicle, and the growth 
has a broad base, the womb is almost certain to be dislocated and 
more or less fixed in an unnatural position. 

'Pressure on the bladder, even without co-existing anteflexion, 
may become so considerable as to compress it between the sym- 



1050 THE DISEASES OF WOMEN. 

physis and the tumor, giving rise, in consequence, to second* 
ary phenomena in the uro-poietic system. 
The hyperemia of the pelvic blood vessels, 
occasioned by fibroid tumors, is frequently manifested in the 
mucous membrane of the bladder as a varicose distention of its 
veins, especially of those situated at the neck of the bladder; 
and Rokitansky even observed a case of rupture of a submucous 
cystic vein, with hemorrhage into the bladder. Thomson relates 
a case in which a perforation occurred in the wall of the above 
organ from pressure of a large fibroid tumor, with adhesion of 
half of the periphery of the tumor to the borders of said per- 
foration. 

" On the other side pressure affects the rectum, and defecation 
may be completely prevented by fibroids impacted in Douglas' 
space. They may also cause varicose distention of the hemor- 
rhoidal veins, and hyperemia of the rectal mucous membrane in 
the same way as in that of the bladder."* 

Hypostatic hyperemia, or engorgement, of the utero-vaginal 

mucous membrane is a very common result of the pressure from 

these tumors. And hence they are likely to be 

Coincident disorders. . . . 

attended, not only with uterine deviations, but 
with a coincident cervicitis, endo-cervicitis, endo-metritis, and 
vaginitis. Such local derangements of the circulation sometimes 
find vent in a critical hemorrhage which is inter -periodic, and 
sometimes (though rarely in this form of fibroid) in copious or 
prolonged menstruation. 

In these extra-mural fibroids there is a marked and character- 
istic tendency to peritoneal inflammation. In many cases this 

lesion is latent and circumscribed, and as a con- 

Liability to peritonitis. . 

sequence adhesions are formed which glue the 
tumor more or less firmly and generally to the neighboring parts 
or organs. At other times patients suffer from acute lancinating 
pains, are sick a few days, with a sharp attack of peritonitis, and 
then recover. Ail the suffering and all the sequele, however, are 
usually, but improperly, referred to the tumor itself. These are 
the adhesions which are encountered on section in gastrotomy. 
Diagnosis. — The frequency with which this class of fibroids is 

* Pathological Anatomy of the Female Sexual Organs, by Julius M. Klob, M.D., etc. 
N. Y. 1868. p. 175. 



SUB-PEEITONEAL FIBROIDS. 1051 

located at the posterior cul-de-sac increases the liability of their 
being mistaken for retroversion or retroflexion 
r^Xxion t . roversI ° n and °f tne womb. But the physical signs will 
enable yon to distinguish them. Perhaps the 
"touch" reveals a tumor which lies in the hollow of the sacrum, 
but it alone is insufficient as a means of diagnosis. The bi-manual 
examination will help you to decide whether the upper and ante- 
rior portions of the uterus are enlarged or the seat of an abnormal 
growth. But it will not serve to differentiate between a fibroid 
tumor in the posterior part of the pelvis and a retroverted or 
retroflexed uterus. To settle this question, therefore, Ave must 
pass the uterine sound. If the point of the instrument looks 
towards the superior strait, as it should, when it has reached the' 
fundus, the tumor is a fibroid, and the uterus is not displaced 
backwards. I should not forget to remind you, however, that, in 
certain cases, these two disorders co-exist. 

Having already detailed the signs by which you would diagnos- 
ticate an extra-uterine fibroid from an ovarian 

From ovarian dropsy. 

tumor or cyst, it is unnecessary to repeat my 
remarks upon that subject. 

So much depends upon the length and size of the pedicle in 
these cases that it is difficult to establish a rule of diagnosis 

between this form of fibroids and pregnancy. 

From pregnancy. . . . 

Ine uterus will be increased in its dimensions 
if the pedicle is short, and if the womb should grow and develop, 
the presumptive signs of pregnancy will be all the more promi- 
nent. There is, however, some considerable difference in the 
form and general character of the abdominal tumor in the two 
cases.- In fibroids, if there is more than one, the outline of each 
can be recognized through the abdominal parietes. If these walls 
are thin, and not inordinately developed, the fibroid is felt to be a 
hard, firm, resistant mass, which imparts an entirely different sen- 
sation to the fingers from that of the elastic fluctuating sensation 
of the gravid uterus. Sometimes it is possible to feel the rounded, 
knob-like masses caused by smaller fibroids which are attached to 
the exterior of the uterus. 

The uterine souffle will be very similar in both ; but the possi- 
bility of hearing the foetal heart-sounds will sometimes enable 



1052 TEE DISEASES OF WOMEN. 

you to decide between them. In fibroids the tumor develops very 
slowly, while in pregnancy the relative rapidity of its growth is 
much more marked. By withholding an opinion for a few weeks 
you may sometimes be able to settle the question of diagnosis very 
positively, on account of the size of the tumor having very much 
increased meanwhile, providing she is pregnant. Unmistakable 
quickening would also be diagnostic, but it must be real and not 
imaginary. 

In the later months, the condition of the os and cervix uteri, 
the more or less regular return of the menstrual flow, the inability 
to feel the movements of the foetus, the depth of the uterus as 
disclosed by the sound (which should not be passed if the signs 
of pregnancy are at all prominent, or unless in very extreme 
cases), will generally enable you to determine the diagnosis cor- 
rectly. Time is, however, an important element in this respect. 
It may require that you make several examinations before your 
final decision is given. If so, and the patient is not in extremis, 
it will be well to allow the intervals between these several exam- 
inations to be somewhat prolonged. 

When pregnancy occurs in the case of a woman who already has 
one of these sub-serous fibroids, it is more likely to extend to term 

without accident than in case of the sub-mucous 
ab?rdon Ve immunity from tumors of which I have spoken, probably for 

the reason that in the former the uterine cavity 
and its mucous membrane are nearly or quite normal. 

In these fibroids the previous history of the case ; the absence 
of grave constitutional symptoms, chill, fever, and a tendency to 

suppuration ; the fact that the tumor has been 

From pelvic cellulitis. - _- _ 

growing lor months or years, and has no neces- 
sary connection with parturition, whether premature or not; 
neither Avith any traumatic or surgical injury ; would serve to 
distinguish this affection from pelvic cellulitis. Add to this that 
in cellulitis the uterus is almost always fixed and immovable, 
while in fibroids it is not so, and you can have no difficulty. 

The tumor that is sometimes formed by impaction of the faeces 
is in no manner connected with the uterus, is posterior to it, does 
From impacts of the not move with it, is doughy to the feel and can 
fseces - be indented on pressure, is accompanied by 

symptoms of paralysis of the rectum, obstinate constipation, rec- 
tal tenesmus, and more or less of intestinal irritation. 



SUB-PERITONEAL FIBROIDS. 1053 

Course and Termination. — Having free space, within the pelvis 

at first, and then within the abdomen, in which to grow, these 

tumors may reach a considerable size, and exist 

Toleration of. . 

m a dormant state for years before they are 
observed or detected. And being, in most cases, unaccompanied 
by alarming or dangerous symptoms, harmless in themselves, and 
benign in their tendencies, their presence may be tolerated for 
many years more. 

Extra-uterine fibroids tend to develop into fibro-cysts, such as 
you saw in the case of Mrs. C. D , in this clinic, some weeks 

ago This cystic degeneration is one in which 

Cystic degeneration. . 

the tumor becomes composite, and instead of 
being made up exclusively of fibro-cellular tissue, as it was origi- 
nally, is composed of compartments, or cysts, which contain a 
quantity of serum, blood, or pus, or of all these commingled. It is 
only in case of the larger fibroids that this particular degeneration 
takes place ; and you should remember that, although it is by no 
means very frequent in the sub-peritoneal fibroids, yet it is much 
more rarely met with in either of the other varieties of this dis- 
ease. 

Prognosis. — Concerning ultimate recovery from. this kind of a 
fibroid you had better promise nothing. Nature may extemporise 

a means of palliation and relief, through an 

Nature's attempts to cure. _ 

arrest of the development ot the tumor, or even 
amputate it spontaneously by attenuation or rupture of its pedicle, 
so that it shall float around like a loose cartilage in the knee-joint, 
causing little pain or inconvenience ; but it is not probable that 
she will remove it entirely. Pregnancy is not so serious a com- 
plication in extra- as it is in intra-uterine fibroids. 

Although such a tumor may possibly co-exist with carcinoma 

uteri, yet it is a settled fact that uterine 

No risk of cancer. • . 1 

fibroids have no malignant tendencies, and do 
not, therefore, develop into cancer. 

Treatment. — Physicians are agreed that, more especially in the 

early stages of these growths, internal medica- 

short-comings of internal t ^ on should suffice for their removal and cure. 

treatment. 

But to say that it ever has cured them is to claim 
too much for our skill. In the present state of our knowledge, the 



1054 THE DISEASES OF WOMEN. 

most that we can expect to accomplish with our remedies is the 
relief of contingent disorders and complications. And whether 
we shall ever improve upon this is largely a matter of "faith and 
works." If these tumors result from a simple hypertrophy of 
tissue, the resolvent powers of our medicines, locally and inter- 
nally used, should be sufficient to arrest their development, if 
not indeed to cure them radically. Perhaps in the future we may 
be more successful with these means than we have been in the 
past. 

One grand difficulty in the way of this result, however, is the 

impossibility of placing such patients under proper treatment in 

the early stage of the disease, when the tumor 

Reasons therefor. '....... , , 

or tumors are in their mcipiency, and when 
specific means would act more promptly and perhaps successfully. 
Another is that the differential diagnosis is so difficult ; and a third, 
that few women with these adventitious growths, or with uterine 
tumors of any kind (especially in these days of prize-surgery), 
are willing to take sufficient time to test the merits of internal 
treatment. 

The only surgical resource in case of the extra-uterine fibroid 
is gastrotomy. If the tumor has a well-defined pedicle, and its at- 
tachments are not very extensive or vascular, 

Surgical treatment. tit t 

it may be removed, and the pedicle ligated, as 
in ovariotomy. A similar operation may suffice in case its stem 
or stalk is broken, and it is floating in the ab- 
dominal cavity. But, even after the abdominal 
incision has been made, if it is found that the growth is glued on 
all sides, and thoroughly amalgamated with the uterus and the 
neighboring parts, it is thought to be best to relinquish the oper- 
ation, to close up the wound and allow the tumor to remain. This 
course is deemed proper because of the danger that would almost 
necessarily follow from the final extirpation of the growth under 
such adverse cireumstances. These dangers include the possi- 
bility of the shock or collapse, haemorrhage, fatal peritonitis and 
septicaemia. 

Hysterectomy, or the removal of the uterus itself, either wholly 
or in part, has sometimes been successfully practised for the rad- 
ical cure for these fibroids. I have already described what is 
known as Freund's operation (page 705), and the more recent 



SUB-PERITONEAL FIBKOIDS. , 1055 

method of ablation devised by Dr. Lane (page 706). You will 

find that, although this operation, like that of 

Extirpation of the ute- ovariotomwas almost a i ways fatal a few years 

rus and the ovaries. - J J 

ago, its statistics are much more favorable 
now. During thirteen years ending with the first of January, 
1878, Pean, of Paris, performed hysterectomy 24 times, with 16 
recoveries and 8 deaths, or with a loss of one third of his cases.* 
I know of no one in America who has had a more remarkable 
experience in the operation for the removal of the uterus than my 

ofood friend Dr. C. Ormes, of Jamestown, New 

Dr. Ormes' eases of y or k. You will find it detailed ill the CliniqW 
uterine extirpation. i 

for May 15, 1881, from which paper we gather 
that out of five cases, three were followed by complete recovery. 
In one ol these cases he reports that ten years after the operation 
the woman was well and hearty. In one of his fatal cases the 
fibroma was complicated with a colloid tumor ot the ovaries, the 
whole mass weighing 51 pounds, the patient's weight in health 
being only 93 pounds. 

*Lecons de Clinique Chirurgicale, etc., par M. le Dr. Pean, etc., Paris, 1879, page 832. 



LECTURE LXIV. 

FIBROID TUMORS OF THE UTERUS. — (CONTINUED.) 

3 k Interstitial Fibroids. Symptoms. Dysmenorrhea, monorrhagia, abortion, sterility. 
Diagnosis. The tenaculum, the sound and dilatation. Treatment, medical and sur- 
gical. TriUin»in menorrhagia from fibromata. Case.— Uterine polypi. Case.— Pathology 
and treatment of. 

Having discussed the special pathology and treatment of those 
fibroids which are denominated intra-uterine and extra-uterine, 
we now come to speak of such as are located within the wall of 
the womb, midway between its mucous and serous coats. These 
tumors, which are not in the uterine, nor yet in the abdominal 
cavity, are commonly known as 

3. INTERSTITIAL FIBROIDS. 

They also have various synonyms such as intra-mural, intra- 
stromal, parietal, and intermediate. These are the round tumors 
proper, for no matter what their size, unless they are forced into 
the uterine or the abdominal cavity, and thereby become oval or 
perhaps pedunculated, their shape is unchanged. They are al- 
ways enclosed within a proper capsule, and, like the other varieties, 
are most frequently located posteriorly with reference to the 
womb. In very rare cases they are met with at the lower segment 
of the uterus, and even in the cervix. But, wherever they are 
found, the neighboring portion of the womb is hypertrophied, 
and all of its tissues are preternaturally developed. 

Symptoms. — The symptoms are more or less grave and trouble- 
some according to the size of the tumor and the tendency to 
inflammation within or about the womb. If 

Uterine deviations. ,, ,, . , , « -. . ■'. , , 

the growth is large, and fixed m the posterior 
wall of the uterus, that organ will necessarily be displaced pos- 
teriorly. For this reason retroversion and retroflexion are almost 
invariably present in these cases. But if the tumor is attached to 
the side of the womb, the latter will, of course, be dragged, or 
made to incline laterally. 

1056. 



FIBROID TUMORS OF THE UTERUS. 1057 

In a considerable proportion of cases there is dysmenorrhcea. 

The difficulty of menstruation is due either to the partial closure 

or the tortuosity of the cervico-uterine canal, 

Dysmenorrhcea. ,.,. -. -. in- 

which is caused by the flexion of the uterus 
and the presence of the tumor ; or to the fact that this foreign 
body almost necessarily excites painful contractions of the 
womb whenever anything is to be extruded. 

In other cases, I think there can be no question that the obstruc- 
tion to the ready exit of the flow in dysmenorrhcea may indirectly 
cause such a tumor to be developed. It is reasonable to suppose that 
such a derangement in the uterine circulation as almost necessarily 
accompanies very painful and tardy menstruation, would beget a 
vice of nutrition that might result in local hypertrophy. And 
thus, in exceptional cases, it might be very difficult, and perhaps 
impossible, to determine whether the dysmenorrhcea was the 
cause or the consequence of the interstitial deposit. 

On account of their nearness to and intimate relations with the 
uterine mucous membrane, there is almost as great a liability to 

monorrhagia in the interstitial as in the sub- 

Menorrhagia. . 

mucous fibroid. Ihe menstrual discharge is 
always too free, and the return of the periods is apt to be more 
frequent than natural. In many cases the flow is prolonged and 
continuous, the blood oozing away constantly. Or the haemor- 
rhage may be sudden and alarming, accompanied by violent pains 
and contractions like those of labor. Not unfrequently this 
condition of things is mistaken for abortion, more especially if 
shreds of membrane and coagula are expelled. 

The tendency to abortion is somewhat less marked than it is 

in the case of intra-uterine fibroids, but this accident occurs more 

frequently in this than in the extra-uterine 

Abortion. . 

variety. We can account for this clinical fact 
upon the theory that this adventitious growth diverts the nutri- 
tive supplies which are needed by the developing embryo. 
Perhaps a better explanation is that the tumor, or fibroid, excites 
such peristaltic contractions as are likely to empty the womb of 
its contents. The unequal development of the uterine wall is 
not without its influence also. 

I have now under treatment two cases of sterility, which are 
due to the presence of parietal fibroids. In both of them the 



1058 THE DISEASES OF WOMEN. 

growths are so situated as to cause violent dysmenorrhcea, and 
so decided a retro-flexion of the womb as ab- 
solutely to prevent the ingress of the semen 
masculinum. Under these circumstances insemination is impos- 
sible. In order to cure these women it will be necessary to 
remedy the displacement. But if conception were attained, they 
would almost certainly abort afterwards, unless the fibroid had 
been disposed of. 

Other incidental disorders are endometritis, cervicitis, leucorr- 
hcea, cystitis, proctitis, rectal ulceration and paralysis, inveterate 
constipation, hemorrhoids, pelvic cellulitis, and pelvi-peritonitis. 

Diagnosis. ■■ — In separating these from other foreign growths we 
are obliged to depend mainly upon physical signs. Examination 
is to be made with the finger per vaginam, and per rectum, and 
with instruments also, of the cervical and uterine cavities. The 
tumor must first be located, and afterwards identified. These 
steps are less difficult, perhaps, than in other fibroids, because inmost 
cases the tumor is pelvic and not abdominal, and because it is so 
located in the hollow of the sacrum as to be more accessible. 

The bi-manual method facilitates the examination by the 
" touch." The patient should be placed upon h^r back, the 
limbs flexed, and the abdominal parietes relax- 
^ The bi-manual examina- e( i. ^he i e ft hand is then to be placed upon 
the hypogastrium and pressure made upon the 
uterus over the pubes, so as to cause it to descend as far as pos- 
sible into the excavation, toward the ostium vaginae ; the index 
finger of the right hand being at the same time within the vagina, 
or the rectum, is made to explore the lateral 

Depressing the uterus. .. . p ,, , , , 

and posterior surfaces or the womb in such a 
manner as to recognize any increased or abnormal development 
of its wall. 

Or, if the woman is corpulent, it may be necessary to draw 

down the uterus with a Sims' or Nott's tenacu- 

The uterine tenaculum. ' . , . ., ,-, -, , 

lum, m order to examine it more thoroughly 

through the retro-uterine space. 

The probe may suffice to indicate the presence of a tumor 
which presses towards the uterine cavity ; but 
in general it will not diagnosticate an intra-mural 

fibroid, excepting upon the principle of exclusion. Thus, if the 



FIBROID TUMORS OF THE UTERUS. 1059 

sound is passed without difficulty or obstruction, and takes the direc- 
tion of the proper uterine axis, the inference is that, if there is a fib- 
roid in the wall of the womb, it cannot be of any considerable size. 
For one of these tumors must almost necessarily displace the organ. 
A sub-peritoneal growth with a pedicle might fill the hollow of 
the sacrum without changing the axis of the womb, but not so 
with an interstitial fibroid. 

However, if } t ou can not satisfy yourselves of the existence of 

an intra-mural tumor, by the conjoined methods of which I have 

spoken, it will be necessary to proceed to clila- 

Dilatation. . . , , , , , , 

tation, m order to be able to. explore the cavity 
of the womb with the finger or other instrument. This ma}' be 
done in the manner indicated in my last lecture. It should be 
done cautiously, however, lest you induce a severe haemorrhage. 

The differential signs between an interstitial fibroid and pelvic 
cellulitis, pelvi-peritonitis, and kindred affections, with which it 
is sometimes complicated, and for which it has been mistaken, 
are the same as those by which you would distinguish these dis- 
eases and other sequelae from sub-mucous and sub-serous fibroids. 

Prognosis. — My own experience leads me to conclude that this 

variety of the myo-hbromata is more amenable to treatment than 

either of the others. Unless it be excessively 

Relative curability. i -i -i -i-ii ii t 

developed, or attended by unusual haemorrhage, 
or other dangerous complications, from which this class of fibroids 
is not exempted, you should not despair of curing your patient. 
A favorable change is likely to follow the menopause. This 
crisis once passed, the chances are that with the subsequent 
atrophy, or senile involution of the uterus and 
^influence of the change t ] ie ovar i es? sucn a growth may also undergo a 

retrograde metamorphosis, and never occasion 
any more trouble. Sometimes, however, these fibroids cause the 
climacteric to be delayed, and the menstrual flux to be substi- 
tuted by prolonged and dangerous haemorrhages, which have a 
fatal tendency. 

In bad cases, where the cervix is long and narrow, as well as 

dense and undilatable, occurring in women who 
ceiS conditlon of the • have never been pregnant, the prognosis is 

generally unfavorable. Indeed, the texture, 
consistenc} r and other physical characters of the neck of the 






1060 THE DISEASES OF WOMEN. 

womb, have more to do than almost anything else with the possi- 
bility and probability of cure, whether by surgical or medical 
means. Other things equal, multiparse are more likely to recover 
than nulliparae. 

While the fatty, calcareous, cartilaginous, and even the osseous 
degenerations which these fibroids sometimes undergo, are to be 

considered as salutary in their tendencies, other 
erat?oii° us f ° rms ° f de§en " varieties of textural change may imply increased 

danger. Suppuration, sloughing, oedema, and 
interstitial haemorrhage are critical processes that will cause you 
the greatest anxiety, and which you will learn are beset with 
extreme peril. The spontaneous enucleation of the tumor is alto- 
gether favorable. An evident inclination in the fibroid to develop 
in the direction of the uterine cavity, and especially to become 
pedunculated, is not of necessity a bad sign, for it may facilitate 
its removal by surgical means, or otherwise. 

When complicated with other diseases, the danger varies with 
the grade and character of the contingent disorder. In women 
of a hemorrhagic diathesis the chances of recovery are not the 
most promising. 

Treatment. — I am aware that there is a sort of histological 
difference between a simple hypertrophy of the uterine wall and 

an interstitial fibroid ensconced m its capsule. 
curable in their incipi- g u ^ ^^g difference is more apparent than real. 

ency. x *- 

The early clinical history of these fibroids is 
so closely related and allied to those changes which take place 
within the same tissues during utero-gestation, and their post- 
partum involution, as to convey a therapeutical hint which prom- 
ises to be of especial service. And I am persuaded, as the result 
of experience, that, in their early stages, these tumors are often 
curable by the use of internal remedies conjoined with very simple 
local means. 

It is therefore a most fortunate circumstance that these pari- 
etal fibroids are more likely to be recognized, and to come under 
our care at an earlier period of their existence than either of 
the other varieties of this affection. It is for this as well as 
for diagnostic reasons, that I have chosen to treat of them 
separately. 

Manifestly, the first duty of the practitioner is, if possible, to- 



FIBROID TUMORS OF THE UTERUS. 1001 

prevent their recurrence. This may sometimes be accomplished 
through the adoption of means that are calcu- 

Prophylaxis. . _ 

lated to ensure the complete and uniform uivo- 
lution of the uterus after delivery ; the free and ready exit of the 
menstrual flow ; to prevent such habitual or permanent deviations 
of the womb, particularly retroversion and retroflexion, as would 
result in its disproportionate development ; the prevention of 
abortion, and its consequent arrest of the organic changes proper 
to pregnancy ; the interdiction of intemperate and fraudulent 
intercourse ; and of the wearing of pessaries, stays, abdominal 
supporters, and of whatever might interfere with a free and unin- 
terrupted distribution of blood through the pelvic and abdominal 
viscera. This preventive treatment is very important. 

And so likewise is the medicinal treatment. The haemorrhage 
and the serous discharges, as well as the symptoms which are 

attendant upon the local inflammation and the 

Medicinal treatment. rv j • £ ^ n • , 

menstrual disorder, artord a series 01 definite 
indications for our remedies. We make requisition upon the 
materia medica for secale cornutum, sabina, sepia, belladonna, 
iachesis, crocus, calcarea carb., staphisagria, arsenicum alb., sili- 
cea, phosphorus, lycopodium, china, thuja, carbo vegetabilis, sul- 
phur, or nitric acid. One of these is given upon specific indica- 
tions — which should be as definite and accurate as possible — and 
its use is persisted in until the symptoms for which it was pre- 
scribed have disappeared. Then another may be chosen. 

I could detail a number of cases in which the careful and per- 
sistent employment of belladonna has removed 

Belladonna. pi it-it 

a limited hypertrophy ot the womb which, but 
for it, would undoubtedly have developed into a fibroid. It was 
given in the third decimal attenuation. 

Lachesis is equally efficacious in certain cases. It seems pos- 
sessed of remarkable virtues as a resolvent, particularly where 

there is a defective involution of the womb. I 

Lachesis. . - 1 

am not aware that any author has mentioned 
this fact, and you will therefore take my individual estimate of 
its value for no more than it is worth. No class of facts needs 
such abundant confirmation as those which are clinical. In my 
hands the best effects have been derived from lachesis in the sixth 
and the twelfth attenuations. 



1062 THE DISEASES OF WOMEN. 

In claiming that these tumors are curable in their incipiency by 

means that are so mild and available, I do not forget that there 

are many sources of fallacy which misdit lead to 

ources of fallacy. . , • >i nn o 

a wrong mierence respecting the efficacy oi 
this or any other plan of treatment. It is not unusual for these 
growths to increase or to decrease in size very rapidly, and 
sometimes to disappear spontaneously. A retrograde metamor- 
phosis may take them out of the way. The climacteric may 
arrest their development ; and other changes may cut off their 
nutrition and cause them to wither. These cures by limitation 
are often placed to the credit of such agencies as animal magnet- 
ism, spiritualism, electricity, and other imponderables, and even 
of medical treatment. But, making due allowance for all these 
exceptional cases, I apprehend, it remains that very great good 
of a positive kind may be done by means of fitly-chosen internal 
remedies. 

Together with these remedies, as already indicated, I am in the 
habit of employing the cotton tampon saturated with pure glyc- 
erine, or with glycerine containing a few 

Local means. 

drops ot the strong tincture ot calendula, of 
hamamelis, hydrastis, or of the same medicine that is being taken 
internally. This is an excellent adjuvant to the cure, and has the 
effect in many cases to avert the recurrence of frequent and dan- 
gerous haemorrhages. 

The surgical treatment contemplates the removal of the tumor 
either by excision or enucleation. Excision by the ligature or 

the ecraseur, not being available in non-peduncu- 

Surgical treatment. _ . 

lated growths, as a rule, and these fibroids 
being interstitial, the main dependence is upon some form of 
enucleation. This operation consists in making one or more free 

incisions into the tumor and through its cap- 

Enucleation. p . 

sule, irom the interior suriace ot the uterus. 
The fibroid is then turned out of its bed and, if possible, detached 
and removed at once. In many cases it is only partially separ- 
ated, and then allowed to slough away, care being taken mean- 
while to avoid pysemia and similar contingencies by frequent 
injections of carbolized or calendulated water, and appropriate 
internal medication. 

Although the risks of this expedient are sometimes very great, 



FIBROID TUMORS OF THE UTERUS. 1063 

still it is growing in favor. It is sometimes resoited to for the 
removal ot the sub-mucous fibroids also, particularly in case of 
such of them as are attached to the uterus by a broad base. 

Dr. Atlee's operation is a modification of this. And so also is 

Dr. I. Baker Brown's plan of coring or "gouging' out a piece 

from the middle ot the tumor and filling the 

Drs. Atlee's and •, ^-^ h % th ^ fa d b dipped lll'olive 

Browns operations. ■> l l 

oil. The idea in both of these operations is to 
impair its nutrition, and to facilitate the sloughing and separation 
of the adventitious growth. 

In some of these cases there is such an exceptional intolerance 
of artificial dilatation of the cervix uteri, both on account of the 

haemorrhage that may follow, and of directly 

Danger in dilatation. . , . |~ , * 

fatal results, that the greatest possible care is 
requisite in the preparation of the patient for the removal of the 
tumor. Dr. Thomas reports two cases of sudden death from the 
use of the sponge-tent preparatory to enucleation, and sums up the 
dangers of this whole operation in the following forcible language: 
"If the cervical canal be well dilated, and the uterus susceptible 
of depression to the ostium vaginae, or the vagina be so dilatable 
as to admit the hand, the case should be regarded as favorable to 
the procedure. If the opposite state of affairs exists, the case is 
not only an unfavorable one, but the procedure will in all proba- 
bility fail. The prospect of success is, for these reasons, much 
better in multiparous than in uulliparous women."* 

TRILLIN IN MENORRHAGIA FROM UTERINE FIBROIDS. 

Case. — Mrs. , aged thirty-three years, a nullipara, has had 

menorrhagia sometimes to a very alarming extent, for eight years 
past. After having lifted and nursed a very sick sister she first 
observed a tumor in the lower part of the abdomen eight years 
ao'o. This tumor grew slowly, was not sensitive, was larger at 

B B - «/ ' - 

the month than directly after the flow, and finally caused symp- 
toms of prolapse of the womb when she was on her feet. When 
she first came to the Clinic she was very weak from the loss of 
blood, from an impaired digestion, improper nutrition, and from 
a depressed mental condition. At one time in the early history of 
the case, and without any apparent cause the menses were sup- 
pressed for nearly a year. She took the third decimal trituration 

* The American Journal of Obstetrics and the Diseases of Women and Children. 
1872. Vol. V,page 10S. 



1004 THE DISEASES OF WOMEN. 

of trillin with the effect to dispose of the monorrhagia, to remove 
all of the symptoms that were dependent upon it, and to check 
the growth of the tumor. Two years have now passed since she 
began the use of this remedy, and thus far there has been no occa- 
sion to resort to any other for the relief of the haemorrhage. 
Meanwhile, however, the growth of the neoplasm has extended 
to the neck of the womb, and so involved its posterior portion 
as to preclude the possibility of extirpating the growth without 
also removing the entire cervix. 

This remedy seems to be especially adapted to the menorrhagia 
and metrorrhagia which are almost always present m cases of 
interstitial and intra-uterine fibroids. For like secale it is of little 
effect in uterine haemorrhage unless from pregnancy or otherwise 
the muscular fibers of the womb have been very decidedly devel- 
oped. Incidentally, in a bad case for which I recommended it to 
my old friend Dr. W. C. Barker, of Waukegan, it not only con- 
trolled the alarming haemorrhage but it also relieved a severe 
neuralgia, and put an end to a tedious and harrassing couo-h that 
had worried and weakened the patient almost as much as the loss 
of blood. 

UTERINE POLYPI. 

Case. — Mrs. X., 39 years old, came to the Clinic a fortnight 
ago for the relief of pelvic pain and distress which she attributed 
to menstrual retention of three months standing* She had always 
been regular before, and felt confident that she could not be preg- 
nant now. She aiso complained ot a full pressing headache which 
was worse at the monthly cycle, although the flow did not appear. 
She had taken various remedies to force the flow but without the 
least e fleet. 

An examination of the os uteri in the field of the speculum 
showed that it was plugged with a polypus, which was examined 
by the class, and then carefully twisted off in their presence by 
the use of a Sims' polypus forceps. 

The next week she reported that the monthly flow followed 
directly after the removal of the growth; that it was normal in 
quantity, quality, and duration; and that with its advent all of 
her pelvic distress and headache had disappeared. 

This was a small mucous polypus that was attached, as most of 
them are, within the canal of the cervix, about 

Mucous polypi. . . 

the internal os uteri. Irom being very vascu- 
lar, these mucous growths are sometimes styled sanguineous; 



UTERINE POLYPI. 



10G5 



and, when they do not obstruct the cervix, are likely to be the 
source of severe haemorrhage. This indeed is a frequent cause of 
intractable menorrhagia. In rare cases these mucous polypi may 
be formed within the uterine cavity, as well as in the canal of the 
-cervix, where they sometimes exist in considerable numbers. 
(Fig. 208). 




Fig. 203. Multiple mucous polypi. (Beigel). 

It is well to remember that, whether single or multiple, these 
polypi may not only give rise to copious haemorrhage at the 
month, but that they may and do sometimes cause the most in- 
tractable form of uterine leucorrhoea. So that, as in the case 
which you have just seen, a polypus may cause 

Common characters- i ., ,„„ ^^.i,,^ 

tics or uterine poiypi. a menstrual suppression, or it may pioduce 
either menorrhagia, metiorrhagia, or a leucor- 
rhoea. This is true of each and all the varieties of uterine polypi, 
whether they are mucous, cellular, glandular, or fibrous in their 
character. 

When these bodies are accessible to the touch, and can be 
brought into the field of the speculum, their 
diagnosis is not difficult. But when they lie 
above the internal os, before the cervix has been developed by 
their presence or pressure, we need to explore for them, and to 
dilate the neck of the womb so that we may find them. For 
this purpose we begin with a sponge-tent, or a Nott's dilator 



Diagnosis. 



UTERINE POLYPI. 



1066 



(Fig. 22), or Atlee's dilator (Fig. 24), and, it necessary, follow 
it up with the careful use of Hunter's uterine dilator (Fig. 62), 
until the finger, or the probe, or both can be readily used for 





Fig. 209. Crushing forceps for uterine polypi. 

the detection, location and measurement of the moroid growth. 
It is a fortunate circumstance that the careful use of these means 
of dilatation causes the uterus to descend, without really drag- 
ging" it down, and to be more readily accessible. 




Treatment. 



Fig. ~l(J. Forceps for uterine polypi. 

When the growth is reached the question of its removal may 
be decided upon. If it is not very large or 
fibrous, it may be twisted with a pair of Sims' 

polypus forceps, or even with Pean's artery forceps (Fig. 48). 

Other varieties of polypus forceps are here upon the table (Figs. 

209,210, 211, 212). 




Fig. 211. Polypus forceps and compressors. 

These instruments act by cutting off the vitality of the growth, 
and facilitating its removal without pain or haemorrhage. But 
if the polypus is too firm in its texture to be taken in this way* 



UTERINE POLYPI. 



1067 



it may be drawn down with a volsellum, and snared with a wire 
through Grooch's old canula (Fig-. 212), or by means of a wire 
eeraseur, of which the curved ones are the best. (Fig. 213). 





Fig. 212. Gooeh's canula. Fig. 213. Wire eeraseur for uterine polypi. 

If the peduncle, or stem of the polypus is narrow and slender,, 
no matter if it is fibrous in its character, Aveling's polyptome is 
strong- enough for its excision (Fig. 214. ) An excellent modifi- 




FiG. 214. Aveling's polyptome. 

cation of this instrument by Dr. Hodge, of Philadelphia, has 
already been used in my clinic. (Fig. 28.) 

When uterine polypi are large and their texture is condensed, 
they may grow slowly, may be accompanied by menorrhagia, the 
development of the uterus as in pregnancy, and by the occur- 



1068 THE DISEASES OF WOMEN. 

rence of uterine contractions that resemble labor, or a threatened 
miscarriage. In rare cases these growths develop 

P ob e pL rrent flbr ° US ra P icll y and £ ive rise t0 copious periodical dis- 
charges of a watery fluid, which sometimes 
causes them to be mistaken for cancer. Under these circumstances 
it hsafe to suspect that the tumor is of the recurrent, or sarcom- 
atous variety, and our prognosis should be carefully guarded. 

In this connection I must remind you of w T hat I have already 
said of the failure of the microscope in deciding upon the real 
nature of some of these suspicious growths. (See page 715). 
The signs that are to be derived from careful clinical observation 
in these cases are really worth more than the report of the best 
microscopist in the world. It is best to say that the exact nature 
of these neoplasms is not absolutely known ; that time is a neces- 
sary element in the prognosis ; that heredity has its influence ; and 
that, after their removal, it is best to wait and see whether they 
will come again before you decide whether they are malignant or 
not. 



INDEX. 



A CLINICAL study of the crises, 
etc., 34. 
Abortion, effects of non-lactation in, 
60. 
a contingent of retroversion of 

the gravid uterus, 313. 
with misplaced pains. 326, 
from over-exertion, 327. 
may become a habit, 327. 
intermittent, 3^7. 
cause of, 330. 
as a cause of disease, 333. 
sequelae of, 334, 329. 
ill effects of wrong diagnosis in, 

335. 
difficulty of recognizing the seque- 
lae of, 335. 
treatment of, 336, 363. 
aconite and arnica in, 337. 
belladonna in, 337. 
local treatment of, 338. 
recurrent, and sub-involution, 

361. 
frequency of, 362. 
types of, 362, 
a peculiar cause of, 362. 
importance of rest in, 363. 
Abortive dyscrasia, a predisponent 
of membranous dysmenorrhcea, 
231. 
Abortionist, sophistries of the, 331. 
Abdominal inspection, 66. 
cramps in pregnancy, 229. 
supporters in uterine displace- 
ments, 599. 
Abscess of iliac fossa, diagnosis of, 
from pelvi-peritonitis, 375. 
of the broad ligament, 403, 
of the mammary gland, 471. 
treatment of, 473. 
local applications in, 478. 
demands a good diet, 474. 
prophylactic treatment for, 477. 
support for breasts during, 479. 
proper diet, during, 479. 
labia majora and of vulvo- vaginal 

gland, 534. 
causes of, 335. 
symptoms of, 535. 
diagnosis of, 536. 
Aconite and arnica in abortion, 337. 



Aconite and arnica in ovaritis. 756 

in pelvi-peritonitis, 380. 

in pelvic cellulitis, 411. 
Acidulated drinks in stomatitis ma- 
tern a, 347. 
Accidental causes of menstrual reten- 
tion, 129. 
Acute diseases, cause of suppressed 

menstruation, 119. 
Adjuvants in spasmodic dysmenor- 
rhcea, 111. 
Affections of cerebro-spinal nerves, 

52. 
After-treatment in ovariotomy, 985. 

do. in Battey's operation, 1031. 
Albuminuria in pregnancy, 297. 

signs of, 298. 

mereurius cor. in, 298. 
Alcohol in pelvic cellulitis, 414. 
Alexander's operation, 648. 

do. rules for, 648. 
Amenorrhea, 113. 

symptoms in, 114. 

definition and varieties of, 113. 

etiology of, 113. 

with incipient phthisis, 116. 

forcing medicines in, injurious, 
115. 

diagnosis of, 115. 

prognosis in, 116. 

treatment of, 116, 128, 130, 140. 

anticipative treatment in, 116. 

insidious complications in. 120. 

when chronic, essentially a glan- 
dular disease, 120. 

the cachexia of, 122. 

pectoral complications in, 124. 

calcarea carbonica in, 124. 

Pulsatilla in, 124. 

alternating with ophthalmia, 124, 

with prolapsus uteri and obsti- 
nate vomiting, 132. 

choreic spasms, 138, 142. 

supra-orbital neuralgia, 143. 

menstrual epilepsy, 169. 

spinal irritation and vomiting, 
144. • 

vicarious haematemesis in, 145. 

failure of dilatation in, 147. 

incision of the cervix in, 147. 

in advanced phthisis, 149. 



1069 



1070 



INDEX. 



Ammonium carb. in stomatitis ma- 

terna, 350. 
Anaemic disorders at the climacteric, 
63. 
murmur in chlorosis, 99. 
Anaemia, and chlorosis, diagnosis of, 
105. 
from conjoined lactation and men- 
struation, 495. 
Analysis of fifty cases, showing date 

of menopause, etc. 510. 
Anasarca following the climacteric, 

525. 
Anatomical predisponents of uterine 

flexions, 622. 
Anatomy of the vulvar orifice, 892. 

of the perineum, 893. 
Ante-flexion of the uterus, 626. 
Ante- version do., 638. 
symptoms of, 638. 
diagnosis of, 639. 
physical signs of, 639. 
reduction of, 639. 
rest and remedies in, 640. 
Antigalactics, 477. 
Aphonia from laryngitis, 781. 
Apis mel. in pelvi-peritonitis, 381. 

in pelvic cellulitis, 413. 
Apocynum can. in uraemia, 309. 
Apthous ulceration of os and cervix- 
uteri, 653. 
symptoms of, 654. 
diagnosis of, 654. 
treatment of, 654. 
reprehensible practice in, 655. 
a constitutional disease, 656. 
remedies for the vesicular stage 

of, 656. 
local treatment foi, 657. 
astringents in, 657. 
Arnica in pelvic cellulitis, 411. 
Arrest of menstruation, when physi- 
ological, 113. 
Arsenicum alb. in stomatitis mater- 
na, 349. 
Ascites, area of dullness in, 94. 
Ascites, 933. 

the "touch" in, 933. 

tapping in, 933. 

care in time and place for tap 

ping in, 933. 
prognostic value of tapping in, 
932. 
Atlee's operation in uterine fibroids, 

1041. 
Aspirator in pelvic hsematocele, 431. 
Asthma and hysteria, 781. 
Assistants and instruments for ovar- 
iotomy, 971. 
Atropine in ovarian neuralgia, 754. 
Auscultation, use and range of, 96. 



Avoidable causes of suppressed men- 
struation, 118. 

BAKER'S hysterectomy, 723. 
Baker Brown's do., 1063. 
Bardenhauer's do. 706. 
Battey's operation, 1025. 
Battey-Tait operation, 1028. 
Battey's operation, normal ovariot- 
omy, 1025. 
in uterine fibroids, 1042. 
Barnes' method of reducing inversion, 

646. 
Baryta carb. in stomatitis materna, 

350. 
Belladonna in amenorrhea, 140. 
in pelvi-peritonitis, 380. 
in menstrual epilepsy, 174 
in abortion, 337. 
in pelvic cellulitis, 411. 
in cystitis, 579. 
in ovaritis, 751. 
Bilious derangement during preg- 
nancy, self-limited, 296. 
remedies for, 296. 
colic during pregnancy, 293. 
local palliatives for, 296. 
prophylaxis of, 297. 
diet, mental and physical exer- 
cise in, 297. 
china in 297. 
at the climacteric, 521. 
Bladder, diseases of the, 560 et seq. 

in retro- flexion of the uterus, 623. 
Blenorrhagia a cause of pelvi-peri- 
tonitis, 372. 
Blood-changes in chlorosis, 102. 

during pregnancy, 50. 
Borax in membranous dysmenor- 

rhoea, 241. 
Breast, changes in, during pregnan- 
cy, 283. 
Bronchoceie, and delayed menstrua- 
tion, 39. 
Bryonia in pelvi-peritonitis, 381. 

in ovaritis, 753. 
Burnside, case of malignant hepatic 
tumor, 943. 



pACHEXIiE, influence of, 44. 
\J menstrual, 44. 

puerperal, 60. 

chlorotic, 107. 

in delayed menstruation, 114. 

which complicates pelvic celluli- 
tis', 402. 

cancerous, 699. 
Calcarea carb. in stomatitis materna, 
350. 

in amenorrhoea, 124. 



INDEX, 



1071 



Carearea phos.in menstrual disorders 

and phthisis, 181. 
Calendula in ulceration of cervix uteri 
611. 

in ovaritis, 755. 
Cancer, uterine, 692. 

varieties of 692. 

causes of. 692. 

haemorrhage in, 693. 

leucorrheal discharge in, 693. 

pain in, 694. 

reflex symptoms»in, 695. 

physical signs of, 695. 

proper speculum for, 696. 

diagnosis of, 696. 

from corporeal cervicitis, 696. 

uterine fibroids, 696. 

polypi, 696. 

syphilitic ulceration,' 697. 

course and duration of, 698. 

the cachexia in 699. 

the copraemic and cancerous com- 
plexion in, 700. 

influence of pregnancy and labor 
upon, 700. 

prognosis in, 700. 

mode of death in, 701. 

treatment for, 701. 

and laceration of the cervix, 701. 

indications for local treatmentin, 
701. 

medical treatment for, 701. 

surgical do., 704. 

extirpation of the uterus in, 705. 

Freund's operation for extirpa- 
tion of, 705. 

Baker's operation, ablation of, 
723. 

epithelial variety of, 708. 
Cantharis in cystitis, 579. 
Carcinophobia, 700. 
Caustics in ulceration of cervix uteri, 

611. 
Causes of pelvi-pcritonitisa source of 

confusion, 372. 
Cauterization, dysmenorrhea from, 

187. 
Cellulitis, pelvic, diagnosis of, from 

peritonitis, 374. 
Cervical inflammation and ulceration, 
47. 

atresia, dysmenorrhea from, 186. 

leucorrhea is not uterine catarrh, 
453. 
Cervical metritis, acute, rare in nul- 
liparae. 438. 

differential diagnosis of, 440. 

treatment of, 440. 

chronic menstrual disorders in, 
444. 

nature and cause of, 445. 

is a post-puerper al affair, 445. 



Cervical metritis, general indications 

for treatment of, 447. 
remedies in, 447. 
stenosis and pelvic hematocele, 

421. 
ectropium in laceration of cervix. 

859. 
Cervix uteri, mode of cleansing, 73. 
apthous ulceration of, 653. 
irritable ulcer of, 658. 
rules for operations upon, 202. 
dilatation of. in dysmenorrhea, 

215. 
laceration of the, 855. 
Changes in the vascular tunic of the 

uterus, 49. 
in the heart during pregnancy, 40. 
in the blood during pregnancy, 

50. 
of climate in stomatitis materna, 

348. 
Characteristics of pelvi-peritonitis, 

368. 
Childhood. 35. 
China in bilious colic of pregnancy, 

299. 
sub-involution, 360. 
Chill and thirst in pelvi-peritonitis, 

370. 
Chlorosis, 39, 97. 

and amenorrhea, 97. 
digestive symptoms in, 97. 
cerebral do, 98. 
cardiac do, 98. 
the pulse of. 99. 
anaemic murmur in, 99 
appetite in, 99. 
incidental symptoms of, 99. 
menstrual irregularitus in, 100. 
and dysmenorrhea, 101. 
in pregnancy, 101. 
discoloration of the skin in, 101. 
mental state in, 101. 
etiology of. 101. 
and scrofula, 102. 
blood changes in, 102. 
and ha3matogenesis, 102. 
the spansemia in, incidental, 103. 
nervous theory of, 103. 
precedes amenorrhea, 104. 
menstrual complications sympto- 
matic, 104. 
and jaundice, 104. 
and anaemia, diagnosis between, 

105. 
prognosis of, 106. 
treatment of, 106. 
danger from incidental disease, 

106. 
remedies for general states, of 107. 
treatment for emotional causes, 

107. 



1072 



INDEX. 



Chlorosis, remedies for the cachexia, 
107. 

iron in, 107. 

citrate of iron and strychnia in, 
108. 

phosphorus and calc. phos. in, 109. 

calcarea carb. in 110. 

kali carb. in, 110. 

ignatia in, 110. 

phosphate of iron in, 110. 

sepia in, 110. 

helonias in, 110. 

menses should not be forced, 111. 

spasmodic dysmenorrhea inci- 
dent in, 111. 

the diet in, 112. 

exercise and travel in, 112. 
Chorea during pregnancy, 818. 

may arise from anaemia, 319. 

from shock, 320. 

more common in primiparae, 320. 

symptoms of, 321. 

may be localized, 321. 

prognosis of, 322. 

fatal form of, 323. 

treatment of, 324. 
Chronic disease cause of amenorrhoea, 
119. 

metritis, sub-involution, etc. 586. 

corporeal cervicitis, 443. 

metritis, of eighteen years, 364. 

cervical metritis, 443. 
Chronic cervical endo-metritis, uter- 
ine leucorrhoea, 451. 

a glandular lesion, 452. 

predisposing causes of, 453. 

is a sequel of labor, 453 

scrofula predisposes to, 453. 

menstruation a predisponent of, 
453. 

tuberculous diathesis a predispo- 
nent of, 454. 

and biliary disorders, 454. 

exciting causes of, 454. 

symptoms of, 455. 

the puriform discharge in, 456. 

the leucorrhoea a symptom in, 456. 

varying character of the flow in, 
4^6. 

pelvic pains and suffering in, 457. 

constitutional effects of, 458. 

is characterized by weakness of 
the eyes, 458. 

quite common among unmarried 
women, 459. 

diagnosis of, 459. 

manner of mopping off the cervix 
in, 459. 

the discharge in, not from an 
ulcerated surface, 460. 

diagnosis of, from cervical metri- 
tis, 460. 



Chronic cervical endo-metritis, prog- 
nosis in, 460. 

treatment of, 461. 

proper diet for, 462. 

vaginal injections not essential 
in, 463. 

topical use of glycerine in, 463. 

indications for calendula and hy- 
drastis, in, 464. 

intra-cervical injections not safe 
in, 464. 

pessaries contra-indicated in, 464. 

escharotics harmful in, 465. 

a fallacious practice in the treat- 
ment of, 466. 

rule for examining the flow in, 
466. 

practical hints in treating, 468. 

remedies for the ovarian irrita- 
tion in, 468. 

menstrual disorders in, 468. 

utero- digestive disorders of, 468. 

utero-pectoral disorders in, 469. 

utero-hysterical disorders in, 469. 

utero- vesical suffering in, 469. 

utero-rectal symptoms in, 469. 
Cicatrization from laceration of the 

cervix, 860. 
Cimicifuga in ovarian neuralgia, 766, 
Circulatory system during pregnancy, 

40. 
Climacteric period, 499. 

predisposition incident to the, 500. 

diseases incident to puberty may 
return at, 501. 

new disorders induced by, 501. 

old complaints disappear at, 501. 

symptoms of the approach of, 501. 

haemorrhage frequent at, 502. 

many imitate pregnancy, 502. 

alimentary symptoms at, 505. 

disorders of the circulation at, 
503. 

nervous symptoms at, 503. 

epilepsy not unusual at, 503. 

disorders of the special senses at, 
504. 

diseases of the respiratory system 
at, 504. 

develops diseases of the genera- 
tive system, 504. 

rheumatism and neuralgia at, 505. 

prognosis of diseases at, 505. 
Climacteric the, 63. 

disorders of the, 69. 

anaemic troubles at, 63. 

nervous troubles of, 64. 

causes of danger at, 506. 

tuberculous diathesis and the* 
506. 

guard against hereditary predis- 
position at, 506. 



INDEX. 



1073 



Climacteric the, treatment at, impor- 
tant, 606. 

remedies tor haemorrhage, at, 507. 

the tendency to phthisis at, 507. 

digestive disorders at, 507. 

disorders of the circulation, 508. 

nervous system at, 508. 

disorders of the generative sys- 
tem at, 508. 

rheumatism and neuralgia, 509. 

the comparative frequency of 
diseases at. 509. 

analysis of fifty cases, showing 
date of, 510. 

hysteria at, with cutaneous erup- 
tion, 511. 

character of eruption at, may in- 
dicate the remedy, 512. 

hysteria at, in woman aged sixtv, 
513. 

incipient paralysis at, 517. 

critical diseases may precede the 
518. 

prophylaxis of the diseases of, 519. 

significance of the discharge at, 
519. 

remedies for the acrid flow at, 
519. 

neurosis following, 520. 

rheumatism at, 520. 

remedies for, 520. 

bilious colic at, 521. 

complications at, 522. 

prolapsus uteri with dropsy at, 
525. 

uterine deviation at, may date 
from parturition; 523. 

dropsy aud constipation at, cause 
of prolapsus, 523. 

treatment by perineal pad, of pro- 
lapsus at, 524. 

internal remedies, and hygienic 
treatment for, 525. 

anasarca at, 525. 

the hemorrhagic diathesis at, 526. 
Climate effect upon menstruation, 

119. 
Clinical history of woman, 36. 

test, 59. 

rule regarding uterine displace- 
ments, 590. 

history of membranous dysmen- 
orrhea, 227. 

hints in treatment of pelvic-cellu- 
litis, 402. 
Clysmic spring water, 5S3. 
Coccyodynia and irritable uterus. 687. 
Colocynth in ovarian neuralgia, 765. 

pelvi-peritonitis, 360. 
Colic Fallopian, 1021. 
Collodion oleaginous, formula, 653. 



Combined touch in uterine flexions, 

627. 
Congenital defects cause of delaved 

menstruation, 114. 
Conjoined manipulation, 76. 

use of speculum and sound, 90. 
Consentaneous mobility in uterine 

fibroids, 940. 
Constipation in pelvi-peritonitis, 379. 

from rectal paralysis, 613. 
Contra-indications for anaesthetics. 

200. 
Convulsions, no prophylactic for, 298. 

puerperal, meic. cor. in, 298. 
Coprsemic and cancerous complexion, 

700. 
Corporeal cervicitis and scanty men- 
struation. 447. 
treatment for, 448. 
tartar emetic in, 449. 
Courty's method of reducing inver- 
sion, 645. 
amputation of, 648. 
Crises in a woman's life, 34. 
Curette in epithelioma, 723. 
Cystitis, 575. 

diagnosis of. from urethritis, 554. 

causes of, 575. 

symptoms of, 575. 

diagnosis of, 516. 

prognosis and treatment, 577. 

topical medication of the bladder 

in, 578. 
Clysmic spring water in, 582. 
medical treatment for, 579. 
belladonna in, 579. 
other remedies in, 579. 
milk diet in, 582. 
surgical treatment for, 580 
Cystocele, 560. 

symptoms of, 560. 
varieties of, 561. 
pathognomonic signs in, 561. 
treatment for, 561. 
operation for, 562. 
Huguier's, 563. . 
Jobert's, 563. 
Vidars 563. 
Thomas' 563. 
Cystotomy, operation for, 580. 
vaginal, objections to, 581. 
Simon's method of, 581. 
drainage in, 582. 



DEFINITION and varieties of pel- 
vic hematocele, 418. 
Delay of puberty, 113. 
Delayed menstruation, 113. 
Depraved nutrition. 38. 
Diagnosis of ovarian dropsy, 932. 



1074 



INDEX. 



Diagnosis from extra-uterine preg- 
nancy, 939. 
of ovarian dropsy from ascites, 

932. 
encysted peritoneal dropsy, 935. 
pregnancy, 936, 279, 289. 
uterine fibroids, 939. 
fibro-cystic growths, 941. 
physometra, 942. 

distension and prolapse of blad- 
der, 942, 
enlargement of liver and spleen, 

942. 
tumors from retention of menses 
and faeces, 944. 
Diathesis, effect of, 38. 
upon menstruation, 42. 
at the climacteric, 526. 
Diet for chlorotic patients, 112. 

woman with mammary abscess, 
480. 
Digestive system in pregnancy, 50. 
in chlorosis, 97. 

derangements of stomatitis ma- 
tern a, 343. 
pelvi-peritonitis, 372. 
Dilatation of cervix in retention of 
menses, 130. 
of urethra as a means of diagnosis, 

etc., 565. 
sponge tents in, 566. 
in dysmenorrhea, 215. 
Diphtheritic ulceration of the os 
uteri, 663. 
constitutional. symptoms of, 663. 
physical symptoms of, 663. 
the pseudo-membrane in, 663. 
is a secondary disease, 664. 
cause of, 664. 
treatment for, 665. 
Diseases cured by puberty, 39. 
caused by pregnancy, 46. 
common to pregnancy, 49. 
cured by pregnancy, 54, 
that co-exist with pregnancy, 53. 
caused by the climacteric, 64. 
cured by the climacteric, 65. 
co- existing with climacteric, 65. 
of pregnancy, 279. 
Disorders of digestion, 52. 
the urinary organs, 52. 
the pulmonary system, 52. 
Double touch in ovaritis, 731. 
Dropsy as a sequel of ovaritis, 740. 
of the heart and hysteria, 779. 
Dyscrasiae which may complicate 

pelvic cellulitis, 404. 
Dysmenorrhcea, obstructive, from 
post- puerperal atresia, 197. 
the result of adhesive inflamma- 
tion, 199. 
a clinical lesson in, 199. 



| Dysmenorrhcea, from stenosis of the 
cervix and peivi-peritonitis, 201 . 

contra-indication for anaesthetics 
in operations for, 200. , 

use of the uterine stem in, 200. 

in retroflexion of the uterus, 202. 

description of, 204. 

causes of, 204. 

symptoms of, 205. 

either the cause or effect of re- 
troflexion, 205. 

use of the sound in, 206. 

sequelae of, from retroflexion, 207. 

indications for treatment of, 207. 

reposition of the organ in, 207. 

stem dilators in, 208. 

membranous, 219. 

medicinal treatment in, 210. 
Dysmenorrhcea, neuralgic, 210. 

symptoms of, 213. 

importance of physical explora- 
tion in, 212. 

entire relief of, by a simple ex- 
pedient, 213. 

causes of, 214. 

relation of the flow to the degree 
of pain in, 214. 

indications for internal remedies 
in, 214, 215. 

warm instead of cold water in, 
215. 

dilatation of the cervix in, 215. 

spasmodic, 215. 

effect of gin in, diagnostic, 216 

opiates in, 216. 

hvsterical indications for ignatia, 
"217. 

remedies in, 217. 

obstructive, definition of, 185. 

causes of, 186. 

from uterine deviations, 186, 202. 

intra-uterine growths, 186. 

cervical atresia, 186. 

cauterization, 187. 

symptoms of, 187. 

cause of uterine tenesmus, 187. 

and reflex disorders, 188. 

and indigestion, 188. 

with faecal and rectal disorders, 
188. 

nervous derangements in, 189. 

menorrhagia infrequent in, 189. 

sterility from, 189. 

diagnosis of, 190. 

use of the sound in, 190. 

the flow in, and what it signifies, 
190. 

prognosis in, 190. 

surgical treatment of, 191. 

dilatation in, 191. 

introduction of instruments in, 
192. 



INDEX. 



1075 



Dysmenorrhea, choice of tents for 
use in, 193. 

failure of dilatation in, 193. 

dangers from the use of dilators 
in, 192. 

barbarous practice in, 193. 

precautions in practising dilata- 
tion in, 194. 

incision of cervix uteri in, 194 

dangers attending, 197. 

precautions in surgical operations 
for, 197. 

and chlorosis, 101. 

and uterine colic, 165. 
Dystocia a factor in pelvic cellulitis, 
393. 



EARLY marriage, 37. 
Eczema of the vulva, 538. 
Electricity and magnetism in men- 
strual headache, 159. 
Elytroplasty for vesico- vaginal ris- 

tulaB, 884. 
Elytrotomy in normal ovariotomy, 

1025. 
Elytrorrhaphy, 618. 
Embryo, life of the. 332. 
Emmet's mode of reducing inversion, 
646. 
laceration of cervix uteri, 866. 
Emmenagogues in amenorrhoea, 124. 
Encysted peritoneal dropsy, diagno- 
sis of, 936. 
Endometritis cervical. (See chronic 

cervical do ) 
Enucleation of ovarian cysts, 1003, 
1009. 
partial, 1009. 
Miner's method of, 1003. 
Ludlam's method of, 1004. 
Epilepsy, menstrual, 168. 
at the climacteric, 503. 
uterine and ovarian, 169. 
with amenorrhoea, 169. 
inter-menstrual, 170. 
non-sexual causes of, 171. 
prognosis in, 172. 
treatment of, 173. 
belladonna in, 174. 
nux vomica in, 174. 
hvoscyamus in, 174. 
rhus tox. in, 174. 
diagnosis of, from hysteria, 791. 
Epileptiform hysteria with irregular 
menses, 175, 172. 
and hystero-epilepsy identical, 

176. 
stages of the fit, 177. 
Landouzy's case of, 177. 
predominating symptoms of, 178. 
Charcot's case of, 178. 



Epileptiform, hysteria, treatment o* 
179. 

diagnosis of, 178. 

prognosis of, 178. 

cardinal indications for remedies 
in, 179. 
Episio-perineorrhaphy, operation of, 

618. 
Episiorrhaphy for vesico-vaginal fis- 

tulse, 887. 
Epithelioma of the uterus, 708. 

nature and clinical history of, 709. 

curette in, 723. 

pathological history of, 710 

insidious course of, 711. 

pain and discharge in, 712 

haemorrhage in, 712. 

inspection of, 713. 

extension of the lesion in, 713. 

development of cachexia in, 714. 

diagnosis, importance of, in, 714. 

the microscope in, 715. 

reliable physical signs in, 715. 

age most common tor, 715. 

diagnosis of, from cervical hyper- 
trophy, 716. 

diagnosis of, from uterine polypi, 
716. 

family history in, 717. 

prognosis in, 717. 

treatment of, 717. 

Dr. Sims' operation for, 718. 

qualifying indications for remov- 
al of, 72 I. 

local treatment for. 722. 
Ergot in sub-involution, 358. . 
Eruption, in dysmenorrhea, etc., 202. 
Ervsipelas is allied to pelvic celluli- 
tis, 392. 
Escharotics, contra-indications for, 

465. 
Excision of a vascular tumor of the 

meatus urinarius, 54y. 
Exciting causes of pelvic haeniatocele, 

420. 
Excoriated nipples, 480. 

most frequent in primiparse, 481. 

local and general causes of, 
481. 

symptoms of , 481. 

may become ulcerated, 482. 

may result in abscess, 483. 

treatment of, 4S3. 

prophylactics of, 483. 

with aphthous ulceration, 484. 

with linear ulcers, 484. 

remedies for, 484, 486. 

choice of nipple shield in case of, 
485. 

benefits of the shield for 485. 
Exercise and travel for chlorotic 
patients, 112. 



1076 



INDEX. 



Exfoliative endometritis and mem- 
branous dysmenorrhea, 243. 

Exploratory incision, 945. 

practical indications for, 948. 

External generative organs, affec- 
tions of, 527. 

Extirpation of the uterus for cancer, 
705. 

Extra-uterine pregnancy, diagnosis 
of, 939. 
and hematocele, 429. 

Eyes, weakness of, a, symptom of 
endo-metritis, 458. 



PAPT]S T ESTOCK. Dr., on apocynum 
in uraemia, 309. 
Faradization in spinal irritation, 829. 
Fashionable pretext for weaning in- 
fants, 475. 
Fallopian colic, 1021. 
Fever, remittent, and monorrhagia, 
262. 

malarial, 263. 
Fibroids, uterine, the elevator in, 92. 

with, monorrhagia, 265. 

trillin in monorrhagia from, 1063. 

the uterine sound in, 92. 

relative frequency of, 1032. 

pathological anatomy of, 1032. 

symptoms of, 1034. 

the haemorrhage in, 970. 

the sponge tent as a haemostatic 
in, 1041. 

incision of the cervix in, 1041. 

Dr. Atlee's operation in, 1041. 

hypodermic injections of ergot, 
1041. 

Battey's operation in, 1042. 

electricity and electrolysis in, 1042. 

an animal diet in, 1042. 

excision of the tumor, 1043. 

dilatation the first step, 1043. 

sub-peritoneal, 1048. 

frequency, number, etc., 1048. 

coincident disorders in, 1050. 

diagnosis of, 1050. 

from retroversion of the uterus, 

* 1051. 

ovarian dropsy, 1051. 

pregnancy, 1051. 

pelvic cellulitis, 1052. 

course and termination of, 1053. 

prognosis of, 1053. 

treatment of, 1053. 

gastrotomy in, 1054. 

extirpation of the uterus and 
ovaries in, 1055. 

Dr. Ormes' cases of extirpation in, 
1055. 

interstitial, 1056. 



Fibroids, dilatation in, 1059. 

symptoms of, 1056. 

diagnosis of, 1058. 

the bi-manual examination m> 
1058. 

the uterine sound in, 1058. 

prognosis in, 1059. 

treatment of, 1060. 

remedies in, 1061. 

surgical treatment for, 1062. 

Drs. Atlee and Baker Brown's' 
operation for, 1063. 
Fistulse, vesico-vaginal, 872. 

recto-vaginal, 887. 

the surgical treatment for, 889. 
Fixity of the uterus in pelvi-periton- 

itis, 370. 
Flexions and versions of the uterus, 
622. 

two peculiarities of, 622. 

anatomical predisponent of, 622, 

varieties of, 622. 

most common, 622. 

the bladder and rectum in, 623. 

diagnosis of, 623. 

the touch in, 623. 

the uterine sound in. 623. 

reposition of the organ in, 624. 

pessaries in, 625. 
Flexion ante, of the uterus, 626. 

comparative frequency of, 626. 

cause and diagnosis of, 626. 

the combined touch in, 627. 

how to pass the sound in, 627. 

Sims' repositor for, 627. 

stem pessaries for, 628. 
Flexion latero, comparative fre- 
quency of, 629. 

causes of, 629. 

symptoms of, 629. 

physical signs of, 629. 

passing the sound in, 630. 

postural treatment for. 630. 

diseases contingent upon, 631. 
Foetal heart sound in pregnancy, 283, 

938. 
Follicular vulvitis, diagnosis of, from 

vulvo-vaginitis, 541. 
Forcing medicines in amenorrhea, 

115. 
Fothergill, on ovarian dyspepsia. 767. 
Frequency of pelvi-peritonitis in 

rheumatic subjects, 373. 
Freund's operation for extirpation of 
the uterus, 705. 

GALACTORRHCEA, 474. 
Gastrotomy in iibroids, 1054. 
Gelsemium in amenorrhoea, 140 
menstrual headache, 159. 
dysmenorrhea, 215, 217, 



INDEX. 



107' 



Gelsemium, membranous dysmenor- 
rhoea, 246. 
pelviperitonitis, 380. 
ovaritis, 752. 
General pathology, 33. 
Genitals, external, the inspection of, 

67. 
Girlhood, 35. 
Gonorrheal ovaritis, 735. 
treatment for, 755. 
and sterility, 749. 
Goodell's operation for recto-vaginal 

fistula, 891. 
Guernsey's elevator in retro-flexion, 
634. 



HAMAMELIS VIEG. in ovaritis., 
752, 755. 

Hammond on arsenic and strychnia 

in chlorosis, 111. 
Hawkes, Dr. W. J. on nausea and 

vomiting of pregnancy, 310. 
Headache, menstrual, 151. 

peculiar symptoms of, 152. 157. 
from uterine deviations, 153. 
cause of, 153. 

ovulation and cephalalgia, 154. 
exciting causes of, 154. 
diagnosis of, from sick headache, 

155. 
from congestive headache, 156. 
from hysterical headache, 156. 
prognosis in, 157. 
treatment of, 158. 
hygienic treatment of, 158. 
electricity and magnetism in, 

159. 
internal remedies for, 159. 
Heart, the changes in during preg- 
nancy, 50. 
do. a predisponent of cardiac dis- 
ease, 51. 
Helmuth's operation for supra-pubic 

lithotomy, 587. 
Helonias in chlorosis, 110. 
Hseinatogenesis and chlorosis, 102. 
Hematocele, pelvic, diagnosis of, 
from pelvi-peritonitis,374. (See 
Pelvic hsematocele, 418.) 
Hemiplegia with menorrhagia, 265. 

hysterical. 810. 
Hemorrhagic tendency, influence of 
the, 43. 
diathesis in pelvic hematocele, 

420. 
remedies in, 260. 
Hemorrhage, post-menstrual, 253. 
post-dysmenorrhceal, 254. 
at the climacteric, 254, 502. 
in uterine cancer, 693. 
Hereditary amenorrhcea, 100. 



Hereditary amenorrhea, tendency to 

suppression, 118. 
Hernia of the ovary, 728, 731. 
Holcombe, Dr. W. H. case of ovarian 
neuralgia, 765. 

on the treatment of pruritus 
vulvae, 534. 
Hot water injections in pelvi-peri- 
tonitis, 379. 
Huguier's operation for cystocele, 

563. 
Hyoscyamus in menstrual epilepsy, 

174. 
Hysteria, the pulse in, 515. 

coffea in, 515. 

and uterine colic, 165. 

at puberty, 39. 

the influence of, 43. 

at the climacteric, 511, 513. 

in a woman aged sixty, 513. 

incident to menstrual life, 514. 

caulophyllin in, 515. 

the pupils in, 514. 

treatment of, 515. 

a factor in irritable bladder, 585. 

and the menstrual molimen, 771, 
772. 

during gestation, 773. 

emotional causes of, 773. 

suspicious symptoms of, 775. 

incongruous symptoms of, 776. 

a species of malingering in, 776. 

leading characteristics of, 777. 

the symptoms of valvular disease 
of the heart in, 778. 

diagnosis of, from dropsy of the 
heart, 779. 

the cough in, 780. 

diagnosis of, from pectoral dis- 
ease, 780. 

hypochondriasis, 787. 
asthma, 781. 
epilepsy, 791. 

from apoplectic aphonia, 782. 

from insanity, 783. 

the delirium of, 785. 

incident to fevers, 786. 

in puerperal peritonitis, 788. 

may counterfeit labor, 790. 

the aphonia of, 781. 

or spinal irritation, 793. 

may locate itself in the joints, 
794. 

not a bona-fide disease, 795. 

treatment of, 797. 

narcotics and anti-spasmodics in 
the treatment of, 800. 

stimulants in, 801. 

domestic occupation a require- 
ment in the treatment of, 802. 

treatment of, during a fit, 804. 

do. in the interval, 806. 



1078 



INDEX. 



Hysteria, general rules in the treat- 
ment of, 807. 

coincident lesions of the uterus 
and ovaries in, 808. 

caused by utero-gastric andutero- 
cardiac derangements, 809. 

from neurasthenia, 810. 

a practical test for, 811. 
Hysterical complications of prolapsus 
uteri, 608. 

diathesis in ovarian neuralgia, 
758. 

hemiplegia, 811. 

remedies for, 814. 

may occur in males, 813. 

prognosis of, 814. 

mimicry, 811. 

diagnosis of, 812. 

ischuria, 572. 
Hysterectomy, vagina], 723. 
Hysterectomy, supra- vaginal, 723. 
Hysterorrhaphy, 648. 
Hystero-epilepsy, 176. 

Landouzy's case of, 177. 

Charcot's case of, 178. 



TGNORANCE and self-neglect, 37. 
X Iguatia in chlorosis, 217. 

do. hysterical dysmenorrhcea, 217. 
Impoverished blood, 37. 
Tncision of the cervix uteri, 131, 194, 

1041. 
Indications for calendula and hy- 
drastin, 464. 

and contra-indications for ovar- 
iotomy, 961, 963. 
Infantile leucorrhoea, 543. 

causes of, 544. 

treatment for, 544. 

isolation essential in, 545. 
Influence of remedies upon the uterus 

and liver, 296. 
Injections, intra-cervical, harmful in 

endo cervicitis, 464. 
Insanity and hysteria, 783. 
Inspection, varieties of, 66. 

of external genitals, 67. 

by the speculum, 67. 

table, chair, and lights for, 72. 

of the rectum by e version, 74. 
Inter-menstrual epilepsy, 1-70. 
Interstitial fibroids of the uterus, 

1056. 
Intestinal resonance, 94. 
Intra-uterine astringents in monor- 
rhagia, 272, 273. 
Inversion of the uterus, 641. 

causes of, 642. 

symptoms of, 642. 

the tumor in, 642. 

diagnosis from procidentia, 643. 



Inversion of the uterus, diagnosis of 
the sub-mucous tibroid,643. 

the crucial test for, 643. 

prognosis in, 643 

treatment of, 644. 

following abortion, 644. 

manual treatment of, 644. 

Tate's vesico-rectal method for 
reducing, 645. 

Courty's rectal do., 645. 

Noeggerattfs method for reduc- 
ing, 645. 

Emmet's do., 646. 

Sims & Barnes' do., 647. 

White's do., 647. 

Thomas' do., 647. 

Courty's method for amputation 
in, 648. 
Iron in chlorosis, 108. 
Irritable bladder, 584. 

causes of, 584. 

hysteria a factor in, 585. 

three points in the diagnosis of, 
585. 

treatment of, 585. 
Irritable ulcer of uterine cervix, 658. 

the speculum not always neces- 
sary in, 659. 

removal of the protective mucus 
from, 659. 

appearance of the, 660. 

a sign of depraved vitality, 660. 

local treatment for, 661 . 

internal remedies for, 661 . 

do. uterus, hysteralgia, 681. 

has no detinite lesion, 682. 

a species of hyperesthesia, 682. 

limited to menstrual life, 682. 

predisposing causes of, 682. 

exciting causes of, 683. 

from abortion, 684. 

from escharotics, 684. 

location of the pain, 685. 

may simulate other diseases, 68& 

nervous symptoms in, 686. 

physical examination of, 687. 

diagnosis of, from coccydynia, 
687. 

from dysmenorrhcea, 6S8. 

treatment for, 688. 

practical hint in, 689. 

surgery contra-indicated in, 690, 

topical expedients in, 690. 

new remedies for. 791. 
Ischuria, hysterical, 571. 



JOBERT'S operation for cystocele, 
563. 
Jousset on the treatment of pelvi- 
peritonitis, 379. 



INDEX. 



1079 



KALI CARB. in chlorosis, 110. 
Kendell, Dr. Lyman, case, 124. 
Kiwisch on ovaritis and pelvic tu- 
mors, 746. 

LABIA MAJORA abscess of, 534. 
Labor a predisponent of proci- 
dentia, 620. 
Laceration of cervix uteri, 855. 

a cause of sub-involution, 862. 

discovery and description of, 855. 

as a cause of uterine cancer, 863. 

puerperal, 855. 

causes of, 856. 

symptoms of, 856. • 

varieties of, 858. 

cervical ectropium in, 859. 

cicatrizations from, 860. 

diagnosis of, 861. 

a singular fact regarding, 861. 

the certain test for. 861. 

and sub-involution, 862. 

and epithelioma, 862. 

and sterility, 863. 

prognosis in operation for, 863. 

prophylaxis of, 863. 

preparatory treatment for opera- 
tion for, 864. 

trachelorrhaphy in, 866. 
Laceration of the vulva and perineum 
— perineorrhaphy, 892. 

of the fourchette, 893. 

perineum, varieties of, 895. 

frequency of, 895. 

symptoms of, 896. 

effects of cicatrization in, 898. 

immediate treatment in recent 
cases of, 897. 

use of serre-fines in, 897. 

primary operation for, 898. 

secondary operation for, 898. 

freshening process in, 898. 

closing the wound in, 899. 

complete operation for, 899. 

and recto-vaginal septum, 902. 

Dr. Tait's method, operation for, 
902. 

after-treatment in, 901. 

results of operation tor, 901. 
Lachesis in ovaritis, 752 
Lactation, 60. 

the natural stimulus to uterine 
contraction, 60. 

effects of in abortion, 60. 

undue effects, 62. 

ill effects of, if prolonged, 476. 

the cause of unilateral neuralgia, 
496. 

and menstruation, anaemia from, 
495. 

extraordinary case of, 497. 



Langenbeck's operation in uterine 

cancer, 706. 
Laparotomy explorative, 945. 

mode of making, 946. 
Latero-flexion of the uterus, 629. 
Latero-version, 640. 

subjective signs of, 640. 

with constipation-, 613. 

physical signs of, 641. 

treatment for, 641. 
Leucorrhoea, the cause of impaired 
lacteal secretion, 489. 

and scrofulosis, 489. 

the cause of illness in the infant, 
491. 

acts as a poison to the child, 491. 

and sterilty, 492, 674. 

treatment for, 492, 680. 

remedies and diet for, 493. 

infantile, 543. 

and ulceration in prolapsus uteri, 
608. 

with chronic ovaritis, 671. 

may substitute menstruation, 673. 

inter-menstrual treatment of, 675. 

and the scrofulous dyscrasia, 676. 

may be critical, 677. 

local and general causes of 677. 

constitutional causes of, 678. 

scrofulosis in, 678. 

remedies for, 680. 

in uterine cancer, 693. 
Leucocytosis, 943. 
Listerism in ovariotomy, 967. 

and drainage, 981. 
Lithotripsy and vaginal cystotomy, 

587. 
Lithotomy, supra-pubic, by Helmuth, 

587. 
Local symptoms of pelvic hemato- 
cele, 423. 
Ludlam's method of enucleation, 1004. 



MACROTLN" in pelvi-peritonitis, 
382. 
with rheumatism, 382. 
with spinal myalgia, 382. 
mental symptoms of, 382. 
Mammary gland, abscess of, 382. 
subsequent treatment of, 474. 
Manual exploration of the rectum, 

80. 
Marriage, early, 37. 
McCleary, Dr. R. B., case of men- 
strual headache, 159. 
Meatus urinarius, vascular tumor of, 

516. 
Medical experience should be quali- 
fied, 59. 
treatment of pelvic hematocele, 
433. 



1080 



INDEX. 



Medical treatment for vaginismus, 

850. 
and mechanical causes of ovari- 
tis, 725. 
Membranous dysmenorrhea, 219,234. 
the membrane in, identical with 

the decidua vera, 226. 
may be overlooked, 225. 

causes of, 225, 235. 
anatomical peculiarities of, 226. 
shape and size of the membrane 

in, 228. 
regularity of appearance in, 228. 
reflex gastric symptoms in, 229. 
expulsion of the membrane in, 

228. 
reflex cardiac symptoms in 229. 
consequent uterine affections 

from, 230. 
diagnosis of, from abortion, 230. 
prognosis in, 230. 
treatment of, 231,239. 
rheumatic complications in, 231. 
the abortive dyscrasia a predis- 

ponent of, 23i. 
from repelled eruptions, 132, 234. 
reflex symptoms in, 132. 
treatment of ovarian symptoms 

in, 132. 
an antiquated prescription for, 

132. 
local applications in, 233. 
sponge tent in, 233. 
comparative frequency of, 234. 
from cutaneous eruptions, 235. 
case of, 236, 238, 241, 243, 245. 
sterility as a sequel of, 236. 
the skin and uterine mucous 

membrane in, 237. 
borax in, 241. 
from exfoliative endo-metritis, 

243. 
mal-treatment of, by pessary, 

244. 
confrra-iuidications for pessary in, 

244. 
peculiar remedies in, 244. 
result of treatment in, 245. 
ovarian, 245. 

button-hole os uteri in, 246. 
gelsemium in, 246. 
Menorrhagia, 247. 

differential diagnosis of, 248. 
modes of examination in, 248. 
complicating lesions of, 248. 
from a miscarriage, 248. 
and ovaritis, 248. 
treatment of, 249. 
remedies during, 249. 
remedies for complications of, 

249. 
surgical treatment of, 251. 



Menorrhagia, nitric acid in, 252, 853. 

with remittent fever, 262. 

and ovaritis, 734. 

complicated with malarial fever, 
263. 

with rheumatism, 263. 

with hemiplegia, 265. 

from a uterine fibroid, 265. 

with convulsions, 266. 

folly of stopping the flow in, 270. 

the gastric and chlorotic symp- 
toms in, 271. 

sudden suppression of, by astrin- 
gents, 271. 

intra-uterine astringents in, 273. 

sometimes salutary, 272. 

physiological argument against 
intra-uterine astringents in, 278. 

digestive disorders from vaginal 
and uterine injections in, 273. 

from polypi, etc , 274. 

treatment of, 274, 277. 

intolerance of vaginal injections 
in, 275. 

and tuberculosis, 180. 
Menorrhcea— cervical epistaxis, 255. 

ks relation to menstruation, 255. 

a diagnostic rule in, 256. 

a physiological reason for, 255. 

peculiarity of the flow in, 257. 

critical nature of the flow in, 257 

necessity of physical examine 
tion in, 258. 

may persist without manifest in- 
jury, 258. 

sterility from, 259. 

treatment of, 259. 

medicine versus surgery in, 259 

not to be confounded with un' 
avoidable haemorrhage, 239. 

remedies for the haemorrhagir 
diathesis in, 260. 
scrofulous diathesis in, 260. 
syphilitic diathesis in, 261. 
ovarian complication in, 261- 

the exercise most important in the 
cure of, 261. 

change of climate may aid the 
cure of, 271. 
Menses, should not be forced in chlo' 
rosis, 111. 

retention of the, 128. 

irregular, with epileptiform hys- 
teria, 175. 

suppression of, 280, 117. 

an uncertain sign of preg- 
nancy, 281. 
marriage as a remedy for, 281. 
Menstruation, 40. 

causes of suffering during, 40. 

three steps in the process of, 40. 

anticipating symptoms in, 41. 



INDEX, 



1081 



Menstruation, accompanying symp- 
toms in, 41. 
subsequent symptoms in, 42. 
influence of diathesis upon, 42. 
travel upon, 42. 
hemorrhagic tendency upon, 
43. 
the exciting cause of relapse, in 

54. 
the exciting cause of intercur- 
rent disease upon, 43, 
the arrest of, when physiological, 

113. 
delayed, 113. 
vicarious, 275. 

Pulsatilla in, 278. 
and pregnancy, 286. 
arrest of, cause of disease, 139. 
nervous phenomena following, 

140. 
frequent, in early phthisis, 179. 
treatment for, 181. 
and tuberculosis, 179. 
predisposes to chronic cervical 

endo-metritis, 453. 
Menstrual retention, etiology of, 129. 
symptoms of, 129. 
and uterine displacements, 160. 
diagnosis of, 129. 
headache, 151. 
epilepsy, 168. 

intermission common, 269. 
irregularities in chlorosis, 100. 
complications in chlorosis, 104. 
suppression and retention not the 

same, 117. 
suppression may be hereditary, 

118. 
suppression, avoidable causes of, 

118. 
relapses the rule in pelvi-periton- 

itis, 372. 
function in pelvic cellulitis, 401. 
life, duration of, 500. 
importance of the change in, 500 
irregularities, cause of uterine 

deviations, 606. 
disorders incident to ovaritis, 733. 
sequelae of, 747. 
Meisuration, 74. 
Mental state in chlorosis, 101. 
Mercurius in stomatitis materna 

319. 
viv. in ovaritis, 752. 
Metritis, acute cervical 437 
varieties of. 438. 

rare in multiparas, 438. 
the monthly cycle a predisponent 

of, 438. 
causes of acute. 439. 
differential diagnosis of, 440. 
prognosis of, 440. 



Metritis, postural treatment for, 440. 
means of preventing, 441. 
local measures in the treatment 

of, 442. 
hot rectal douche for, recom- 
mended by Dr. Chadwick, of 
Boston, 442. 
chronic, cervical, 443. 

mechanical symptoms of, 444. 
chronic, direct and reflex symp- 
toms of, 444. 
menstrual disorders in, 444. 
nature and cause of, 445. 
may be connected with hepatic 

disease, 445. 
is a post-puerperal affair, 445. 
diagnosis of, from uterine cancer, 

445. 
diagnosis of, from corporeal me- 
tritis, 446. 
a new diagnostic test for, 446. 
prognosis of, 446. 
requires postural treatment, 446. 
general indications in the treat- 
ment of, 447. 
remedies in, 447. 
local adjuvants in, 447. 
Metro-peritonitis, origin of, 48. 

cerebral disorders in, 52. 
Metrorrhagia after abortion, 252. 

nitric acid in, 252. 
Microscope in epithelioma of the 

uterus, 715. 
Miner's, Prof. J. F., method of enu- 
cleation in ovariotomy, 1003. 
Molar pregnancy, 284. 
Morning sickness of pregnancy and 

retro-version, 311. 
Multipara? effects of parturition in, 
56. 



NAJA in ovarian neuralgia, 765. 
Narcotics and anti-spasmodics 
in hysteria, 800. 
Natrurn mur. in stomatis materna, 

350. 
Nausea and vomiting of pregnancy, 
304. 
sometimes fatal, 304. 
remedies for, 307. 308. 
a frequent symptom in pelvi- 
peritonitis, 370. 
in the after treatment of ovariot- 
omy, 990. 
Nervous exhaustion, 3S. 
system in pregnancy, 50. 
in parturition, 55. 
uterine disease, 61. 
troubles at the climacteric, 64. 
and vascular system in amenor- 
rhcea, 121. 



1082 ' 



INDEX. 



Nervous exhaustion, theory of chlor- 
osis, 103. 
and menstrual functions, 270. 
symptoms at the climacteric, 503. 
in prolapsus uteri, 608. 
of irritable uterus, 686. 
Neuralgia, menstrual, varieties of, 143. 
cutaneous of pregnancy, 301. 
symptoms of, 301. 
unilateral, from prolonged lacta- 
tion, 496. 
Neuralgic dysmenorrhea, 210. 

diathesis, 757. 
Nidation, a factor in menstruation, 

234. 
Nipples excoriated, 480. 

loss of, from erysipelatous inflam- 
mation, 494. 
Nitric acid in menorrhagia, 252, 253. 
Noeggerath's method of incision in 
ovariotomy, 943. 
mode of reducing inversion, 645. 
Normal ovariotomy— Battey's opera- 
tion, 10251 
Non- specific urethritis, 551, 555. 
causes of, 552. 
symptoms of, 553. 
character of the urine in, 553. 
diagnosis of, from stone, 554. 
cystitis, 554. 
gonorrhoea, 554. 
Nursing, a prophylactic of uterine 

disease, 61. 
Nux vomica in menstrual epilepsy, 

174. 
Nymphomania and ovaritis, 750. 



OLDHAM'S theory of ovarian influ- 
ence, 227, 246. 

clinical confirmation of, 227. 
Omental aunesions in ovarian tumors, 

975. 
Operation for vesico-vaginal fistulse, 
880. 
recto-vaginal ristulse, 887-9. 
laceration of the perineum, 897. 
removal of ovarian cysts, 960. 
Oophorectomy, 1025. 
Opiates in spasmodic dysmenorrhoea, 

216. 
Origin of pelvic peritonitis, 49. 

pelvic cellulitis, 49. 
Ormes, extirpation of the uterus, 963, 

990. 
Os uteri, diphtheritic ulceration of, 
constitutional symptoms of, 663. 
Ovarian dysmenorrhoea, 245. 

irritation and chronic cervical 

endometritis, 468. 
tumors during pregnancy, 53. 
resolution of, 746. 



Ovarian dysmenorrhoea, atrophy and 
induration, treatment for, 754. 
neuralgia, ovaralgia, 756. 

peculiar predisnonents of. 

757. 
the neuralgic diathesis and, 

757. 
rheumatic diathesis and, 758. 
hysterical diathesis and, 758. 
organic disease of uterus and 
ovaries a fertile source of,, 
759. 
Ovarian neuralgia, peculiar sensa- 
tions in, 759. 
sexual excitement a fertile* 

source of, 758. 
when incident to menstrual 

disorders, 760. 
cause of the pain in, 760. 
peritoneal adhesions a cause 

of, 760. 
diagnosis of, from ovaritis, 
761. 
from hernia, 761. 
from uterine neuralgia, 
761. 
prognosis of .761. 
treatment «,£ 762. 

for «tie rheumatic com- 
plications in, 762. 
topical, 762. 
valerianate of zinc in, 764. 
atropine in, 764. 
colocynth in, 765. 
naja in, 765. 

ammonium carb in, 765. 
cimicifuga in, 766. 
irritation, case of, 766. 
dyspepsia, by Dr. Fothergill, 767. 
irritation at the climacteric, 768. 
a pathognomonic s«gnof,768. 
exciting causes of, 769. 
Dr. Woodward's case of, 769. 
remedies for, 770. 
Ovarian dropsy, area of dullness in,, 
95. 
diagnosis of, from pelvic hsemato- 
cele, 429. 
from ascites, 932. 
tapping in, 933. 
refilling of the cyst in, 935. 
frequently confounded with preg- 
nancy, 936. 
changes in the cervix in, 937. 
length of uterine <uavity in, 937. 
rapidity of growth of, 937. 
difficulty of diagnosis of, from 

fibro-cystic growths, 941. 
from enlargement of liver and 
spleen, 942. 
Ovario-rjeotoral sympathies, 120, 
Ovaritis, 724. 



I1NDEX, 



iosa 



Ovaritis and menor.rhagia, 248. 
chronic, with leucorrhoea, 671. 
the burning pain of, 672. 
ovulation sometimes a constant 

cause of, 672. 
may cause uterine and vaginal 

catarrh, 673. 
sub-acute form of. most frequent 

724. 
generally symptomatic, 724. 
from dysmenorrhea, 725. 
from medical and mechanical 

causes, 725. 
epidemic form of, 726. 
peculiar pain in, 727. 
traumatic, 727. 
peritoneal form in, 728. 
vaginal touch in, 730. 
characteristic pains of, 730. 
rectal touch in, 731. 
the "double touch" applied in, 731. 
prolapse of the ovary and, 730. 
sometimes produces a feeling of 

strangulation, 732. 
vesical symptoms in, 732. 
and menstrual disorders, 733. 
and menorrhagia, 734. 
gonorrhoeal, 735. 
pathological anatomy of, 738. 
the lesion of, varies, 738. 
the discoloration and clot in, 739. 
haemorrhage into the ovary from, 

740. 
dropsy as a sequel of, 740. 
is liable to terminate in suppura- 
tion, 741. 
character of the pus in, 741. 
extemporized outlets for pus in, 

742. 
variolus, 744. 
diagnosis of, 744. 
characteristic symptoms of, 744. 
danger of, after abortion, 745. 
as a contingent of lying-in, 745. 
danger from suppuration in, 745. 
Kiswisch says of , and pelvic tu- 
mors, 746. 
and ovarian tumors, 746. 
drain from excessive discharge 

following suppuration in, 747. 
consequence of structural change 

from, 747. 
menstrual sequelae incident to, 

747. 
may implicate the uterine mucous 

membrane, 748. 
sterility from, 748. 
gonorrhoeal, and sterility, 749. 
may induce nymphomania, 750. 
general treatment of, 750. 
belladonna in, 751. 
colocynth in, 751. 



Ovaritis, veratrum viride in, 752. 
mercurius vivus in, 752. 
hamamelis virg. in, 752, 755. 
gelsemium in, 753. 
lachesis in, 752. 
bryonia alb. in, 752. 
gonorrhoeal, treatment for, 755. 
calendula in. 755. 
puerperal, 755. 
arnica and aconite in, 756. 
proscribe sexual intercourse in. 

756. 
Ovarian tumors, 905 t 
varieties of, 905. 
cysts, normal anatomy of, 905. 
cysts, contents of, 906. 
cysts, clinical history of, 909. 
cysts, physical signs in, 910. 
cysts, dermoid, morbid anatomy 

of, 912. 
cysts, dermoid, diagnosis of, 914. 
fibroids, clinical history of, 915. 
fibroids, laparotomy in, 917. 
malignant tumors, 918. 
cysto-sarcoma, 918. 
cysto-sarcoma, aspiration in, 922. 
cysto-sarcoma, case of, 923. 
cysto-carcinoma, 925. 
cysto-carcinoma, clinical history 

of, 925. 
echirrhus, history and symptoms- 

of, 926. 
colloid, or myxoma, 926. 
colloid, not always cancerous, 926. 
papilloma, and epithelioma, 927. 
cauliflower degeneration, 927. 
cauliflower degeneration, case of, 

928. 
eucephaloid, case of, 930. 
Ovariotomy, abdominal, 960. 
suitable cases for, 961. 
early indications for, 961. 
immediate indications for, 962. 
contra-indications for, 963. 
double, case of, 964. 
preparatory treatment, 966. 
asepsis and anti-septics in, 967. 
day and season for, 968. 
anaesthesia in, 970. 
instruments for, 971. 
preparing the patient for. 972, 
opening the peritoneum, 973. 
the adhesions in, 975. 
steps of the operation, 970. 
treatment of the pedicle, 977. 
peritoneal toilet in, 980. 
drainage in, 981. 
after-treatment of, 985. 

importance of, 985. 

temperature of the room, 986. 



1084 



INDEX. 



Ovariotomy, after-treatment, 985. 

shock and reaction, 986. 

pain and restlessness, 986. 

the pulse, 986. 

the clinical thermometer, 987. 

nausea and vomiting, 990. 

sepsis and peritonitis, 991. 

gastric and enteric ulceration, 991. 

the urine, 993. 

salines in peritonitis, 994. 

care of the drainage tube, 995. 

dressing of the wound, 995. 

Reopening of the wound, 996. 

secondary haemorrhage in, 996. 

contingent affections, 998. 

results in, 1000. 

by enucleation, 1003. 

Miner's method of, 1003. 

Ludlam's method of, 1004. 

by partial inucleation, 1009. 

vaginal, 1013. 
Ovary, prolapse of the. 728,730. 

ar excellence the organ of men- 
struation, 732. 
Ovulation sometimes the cause of 
ovaritis, 672. 

PAGE, Dr. M. F. on gelsemium in 
dysmenorrhea, 215. 
veratrum vir. in dysmenorrhea, 
215, 
Pain and discharge in epithelioma of 

the uterus. 712. 
Palpation, abdominal. 75. 

vaginal, 75. 
Paralysis and procidentia uteri, 607. 
Parturition, 55. 

effects of, on the nervous system, 

55. 
in primiparae, 55. 
effects of, in multiparas, 56. 
traumatic lesions during, 56. 
Pathognomonic signs of vesico- vagi- 
nal fistulae. 874. 
Pectoral complications of amenor- 
rhea, 124. 
Pedicle, treatment of, in ovariotomy, 

977. 
Pelvic cellulitis. 49, 385. 
synonyms of, 386. 
frequency of. 387. 
four stages of, 387 
intra-pelvic pain in, 388. 
formation of the tumor in, 388. 
location of the tumor in, 389. 
symptoms of second stage, or the 

effusion in, 385. 
incidental symptoms of, 389. 
the third stage may be wanting 
in, 390. 



Pelvic cellulitis, conditions that pro- 
mote resolution in, 390. 
fourth, or suppurative stage of, 

390. 
accompanying hectic of, 391. 
seat of fluctuation in the tumor 

of, 391. 
diagnosis of the presence of pus 

in, 391. 
varied means of escape for pus 

in the tumor of, 392. 
essential nature of, 392. 
is probably allied to erysipelas, 

392. 
one of the contingencies of lying- 
in, 392. * 
is a sequel to dystocia, 393. 
a contingent of uterine surgery, 

393. 
may be complicated with other 

diseases, 393. 
diagnosis of, sometimes difficult. 

394. 
diagnosis of, from pelvi-peritoni- 

tis, 394. 
and pelvi-peritonitis mav co-ex- 
ist, 396. 
and pelvic hematocele, 396. 
diagnosis of, from uterine fibroids 

396. 
sequelae of. 397. 
prognosis of, 397. , 
epidemic, tendency of. 398. 
traumatic causes of, 399. 
in paludal districts, 400. 
prognosis of, will vary according 
to the complicating disease, 400. 
the complicating lesions of, 400. 
a new version of an old fact con- 
cerning, 401. 
condition of the menstrual func- 
tion in, 401. 
sometimes accompanied by mon- 
orrhagia, 402. 
and the treatment to which the 
patient has been subjected, 402. 
a clinical hint in the treatment 

of, 402. 
usually the result of pyaemia in 

the puerperal state, 403. 
may be complicated with abscess 

of the broad ligament, 403. 
may be associated with vesical 

lesions, 404. 
and the dyscrasia upon which it 

has been engrafted. 404. 
and the cancerous cachexia. 405. 
and pelvi-peritonitis usually fol- 
lowed by tuberculosis, 405. 
treatment of, 409. 
pathological deductions from , 410. 



INDEX. 



1085 



Pelvic cellulitis, general indications 
for the treatment of, 410. 

aconite in, 411. 

arnica in, 411. 

belladonna in, 411. 

veratrum viride in, 411. 

local adjuvants in, 413. 

remedies for the stage of effusion 
in, 413. f 

apis mellifica in, 413. 

demands a good diet, 414. 

alcohol very beneficial in some 
cases of, 414. 

emollients in the treatment of, 
416. 

best treatment for the suppura- 
tive stage in, 416. 

how to open the abscess in, 416. 

after-treatment of. 417. 
Pelvic Haematocele, 418. 

definition and varieties of, 418. 

not constant in its clinical his- 
tory, 419. 

causes are predisposing and ex- 
citing, 419. 

may arise from sexual excess, 419. 

influence of age and sexual vigor 
in the production of, 419. 

most frequent in the haemorrhagic 
diathesis. 420. 

one of the sequelae of pelvic peri- 
tonitis, 420. 

pachy-pelvi-peritomtis a predis- 
ponent of, 420. 

exciting causes of, 420. 

may arise from cervical stenosis, 
421. 

source of, 422. 

local symptoms of, 423. 

signs of, per vaginam. 423. 

Voisin's description of formation 
of the tumor in, 424. 

fixation of the uterus in, 425. 

general symptoms of, 426. 

the coincident peritonitis in, 426. 

pain and other symptoms in, 427. 

the anaemia in, 428. 

diagnosis of, from pelvic celluli- 
tis, 428. 
from uterine fibroids, 428. 
from ovarian dropsy, 429. 
from extra-uterine pregnan- 1 

cy, 429. 
from retro-version of the ; 
uterus, 431. 

the aspirator and exploring 
needle in, 431. 

prognosis in, 431. 

treatment of, - may be palliative, 
medical and surgical, 432, 433, 
435. 

indications for tapping in, 436. 



Pelvic haematocele, contra-indica- 

tions for tapping in, 435. 
Pelvi-peritonitis, 367. 

clinical History of, 367. 
varieties of, 368. 
symptoms of, 368. 
different stages of, 368. 
origin of, 49. 

stenosis of the cervix and dys- 
menorrhea, 201. 
the pain in, 368. 
special characteristics of, 368. 
tympanitis seldom lacking in, 369. 
facial expression in, 369. 
the temperature and pulse in. 369. 
the posture most common in, 369. 
nausea and vomiting most fre- 
quent in . 370. 
and its effects upon the menses. 

370. 
the chill and thirst in. 370. 
stage of effusion in, 370. 
three points to be observed in 

local examination of. 370. 
fixitv of the uterus often follows, 

370. 
the tumor in, 371. 
menstrual relapses the rule in, 

372. 
tends to digestive and reflex dis- 
orders, 372. 
may result from Menorrhagia. 372, 
causes of, a source of confusion, 

372. 
most frequent in rheumatic pa- 
tients, 373. 
diagnosis of, 374. 

from pelvic cellulitis, 374. 
from pelvic haematocele, 374. 
from parenchymatous metri- 
tis, 374. 
from abscess of the iliac fossa, 
375. 
prognosis of, 375. 

in the adhesive variety, 375. 
in the puerperal and second- 
ary forms, 276. 
in tuberculous subjects, 376. 
treatment of, 376. 
importance of rest in cases of, 

376. 
local treatment of, 377. 
a substitute for opium in, 378. 
mode of applying hot-water injec- 
tions in, 379. 
. with induration, treatment for, 
379. 
obviate the constipation in. 379. 
a clinical hint in cases of. 379. 
Jousset on general treatment of, 

379. 
aconite in, 380. 



1086 



INDEX. 



Pelvi-peritonitis, colocynth in, 380. 
belladonna and atropine in, 380. 
gelsemium in, 380. 
Bryonia in, 381. 
apis mellinca in, 381. 
terebinth in, 381. 
the salicylate of soda in, 381. 
macrotin in, 382. 
rheumatic, macrotin in, 382. 
with spinal myalgia, macrotin in, 

382. 
mental symptoms in, 382. 
Percussion, posture of the patient 
during, 95. 
in uterine tumors, 96. 
Perineum laceration of, 892. 
anatomy of the, 893. 
physiology of, 894. 
perineorrhaphy, 898. 
primary and secondary, 898. 
Tait's method, 902. 
Peritonitis, pelvic, 367. 
varieties of, 368. 
temperature and pulse in, 369. 
diagnosis of. 374. 
treatment of, 376. 
Jousset on the general treatment, 

of, 379. 
remedies most useful in. 380, 381, 
382. 
Pessaries in uterine displacements, 
596. 
when indicated in prolapsus 

uteri, 611. 
contra-indicated, 244. 
Phosphorus and calc. phos. in chloro- 
sis, 109. 
Physical diagnosis in gynecology, 66. 
exploration in obstructive dys- 

menorfboea, 212. 
examination in menorrhagia, 258. 
signs of epithelial cancer. 715. 
exploration in diagnosis, 943. 
Physometra,880. 

the tumor in, 831. 
decomposition of organic matter 

a cause of, 832. 
diagnosis of, 832. 
treatment for, 833. 
and ovarian dropsy, 942. 
Position of the patient in using the 

uterine sound, 89. 
Post-climacteric affections, 65. 

dysmenorrhoeal hemorrhage, 254. 
Post-partum ulceration of the womb, 
665. 
likely to be overlooked, 666. 
a sequel of inflammation, 666. 
due to an impaired quality of the 

blood, 667, 
treatment for, 667. 
topical applications in, 668. 



Post-partum -ulceration of the womb, 
interdiction of coitus in, 669. 
allowable local treatment in, 670. 
Post-puerperal atresia, a cause of dys- 
menorrhea, 197. 
diseases, 353. 
Post-surgical peritonitis, 202. 
Predisposiug.causes of chronic endo- 
metritis, 453. 
of disease at the climacteric, 506. 
Pregnancy, 45. 

the physiology of, 45. 
the diseases caused by, 46. 
uterine displacements in, 46. 
irregular development of uterus 

in, 46. 
twisting of the womb during. 46. 
effects of, upon the uterine liga- 
ments, 47. 
cervical inflammation and ulceis 

ation during, 47. 
effects of, upon the cervix, 47. 
changes of the endometrium in, 

47. 
peritoneal changes during, 48. 
common diseases of, 49. 
the rheumatism of, 51. 
disorders of digestion in, 52. 
of urinary organs in, 52. 
of pulmonarv system in, 52. 
diseases cured bv, 53. 
diseases that co-exist with, 53. 
the vis medicatrix of, 53. 
effects of phthisis upon, 53. 
influence of, upon coincident dis 
ease, 53. 
of, upon ovarian tumors, 53, 
the uterine tumor in, 94. 
chlorosis in, 101. 
diagnosis of, from amenorrhcea. 

122. 
diseases of, 279. 
differential diagnosis of, 279. 
uterine obliquities in, 282. 
changes in the breast in, 282. 
the foetal heart- sound an unmis- 
takable sign of, 283. 
changes in the cervix during, 283. 
the uterine souffle not diagnos- 
tic of, 283. 
molar, 284. 

the morbid anatomy of, 284. 
influence of age upon, 285. 
retention of the embryo in, 

286. 
and menstruation, 286. 
probable signs of, 286. 
cause of the delivery in, 287. 
excessive abdominal development 

in, 288. 
size of the abdomen as a sign of, 
289. 



INDEX. 



1087 



Pregnancy, diagnosis of, 2S9. 

the induction of premature labor 

in, 292. 
Pulsatilla in mal-presentations 

during, 292. 
bilious colic during, 293. 

vascular relation between the 
uterus and liver during, 293. 

vascular changes in the uterus 
during, 294. 

bilious symptoms in early, 294. 

cholestrsemia contiugent upon, 
295. 

albuminuria in, 297. 

prophylaxis of bilious colic of, 
297. 

mercurius cor. in albuminuria 
during, 298. 

abdominal cramps in, 299. 

spurious peritonitis during, 300. 

diagnosis of spurious peritonitis 
from cutaneous neuralgia dur- 
ing, 301. 

uterine colic during. 302. 

gastro-intestinal disorders inci- 
dent to, 302. 

gastro-intestinal disorders, treat- 
ment of, 303. 

nausea and vomiting of, 304. 

nausea and vomiting of, is some- 
times fatal, 304. 

significance of a coincident jaun- 
dice during, 305. 

morning sickness of, may depend 
upon uterine deviations, 305. 

no specific for the nausea of, 305. 

special indications for remedies 
in morning sickness of, 307. 

remedies for nausea and vomit- 
ing of, 307, 308. 

stretching the cervix in morning 
sickness of, 308. 

the expediency of abortion in 
morning sickness of, 398. 

dangers arising from morning 
sickness of, 309. 

varicose veins during, 310. 

morning sickness and retrover- 
sion of, 311,312. 

reflex gastric symptoms in early, 
312. 

morning sickness of, if not exces- 
sive, may be salutary, 313. 

uterine sound in retroversion 
during, 315. 

postural treatment for retrover- 
sion during, 315. 

chorea during, 318. 

rheumatism a predisponent of 
chorea during, 319. 

effects of, upon uterine cancer, 
700. 



Procidentia, pessaries for, 618. 

elytrorrhaphy for, 618. 

episio perineorrhaphy for, 618. 

from pertussis, 619. 

labor a predisponent of, 620. 

treatment for, 62i. 

taxis and reduction in, 621. 
Prolapsus uteri and procidentia, 602. 

obstinate vomiting with, 132. 

frequency of, 603. 

with dropsy at the climacteric, 
522. 

consequences of incorrrect diag- 
nosis of, 603. 

unnecessary manipulation in, 603. 

spontaneous cures of, and quack- 
ish claims, 604. 

internal remedies in, 604. 

with superficial ulceration of the 
cervix, 605. 

irregular menstruation a cause 
of, 606. 

lumbar and sacral pains in, 607. 

and paralysis, 607. 

hysterical complications of, 608. 

reality of the nervous symptoms 
in, 608. 

leucorrhcea and ulceration in, 608. 

ulceration from the abrasion of, 
609. 

treatment for, 610. 

contra-indications for pessaries 
in, 611. 

caustics in ulceration with, 611. 

with ulceration, calendula in, 611 . 

with right latero- version, 611. 

and constipation from rectal par- 
alysis, 613. 

cramping pains in, 613. 

vesical symptoms in, 614. 

leading indications for treatment 
in, 615. 

with anterior inclination of the 
fundus uteri, 616. 
Prolapse of the ovary and ovaritis, 

728, 730. 
Pruritus of the vulva, 528 

causes of, 528. 

from trichiasis, 529. 

clinical history of, 529. 

may arise from self-inflicted 
wounds, 530. 

may precede menstruation, 530. 

with dysmenorrhcea and amenor- 
rhea, 530. 

at the climacteric, 530. 

during pregnancy, 531. 

may be complicated with uterine 
disease, 531. 

may be limited to the period of 
lactation, 531. 

prognosis of, 532. 



1088 



INDEX. 



Pruritus of the vulva, topical pallia- 
tives, 532. 

with vulvitis, 533. 

if due to pediculi, etc., 533. 

internal remedies for, 533. 

Dr. Holcombe's treatment for, 
534. 

other remedies for, 534. 
Pseudo-membrane in diphtheritic 

ulceration of the os uteri, 663. 
Puberty 35. 

and nubility not the same, 36. 

delayed, causes of, 37, 113, 114. 

impoverished blood at, 37. 

nervous exhaustion at, 38. 

effects of the tuberculous habit 
in, 38. 

delayed, and bronchocele, 39. 

diseases cured by, 39. 

hysteria at, 39. 

the diseases of, 97. 

emuienagogues at, 268. 
Puerperality, 57. 

diseases of, self-limited, 57. 
Puerperal cachexia, 60. 

ovaritis, 755. 
Pulsatilla in mal-presentations, 292. 
Pyaemia and pelvic cellulitis, 403. 



T)ECTAL touch, 78. 
XL in ovaritis, 731. 
Recto-abdominal touch, 79. 
vesical touch, 79. 
vaginal touch, 79. 
Recto-vaginal fistulse, 887. 
causes of, 888. 
physical signs of, 888. 
prognosis in, 889. 
surgical treatment for, 889. 
after treatment in, 890. 
Dr. Goodell's operation for, 891. 
Rectocele, operation for, 562. 
Rectum, inspection by forcible ever- 
sion of, 74. 
manual exploration of, 80. 
Recurrent abortion from mal-lacta- 

tion, 487. 
Reflex relations of the uterine cervix 
and stomach, 658. 
do. of the ovary, 672. 
Repelled eruptions, cause of mem- 
branous dysmenorrhea, 231, 
234. 
Reposition of a retroverted gravid 

uterus, 314. 
Results in the operation for lacera- 
tion of the perineum, 901. 
Retention of the menses, 128. 
accidental causes of, 129. 
and uterine displacements, 160. 
treatment of, 162. 



Retro-flexion of the uterus, a cause 
of dysmenorrhea, 202. 
most common, 622. 
Retro-version, pessaries for, 316. 

and morning sickness of preg- 
nancy, 311,312. 
uterine sound in, 315. 
symptoms of, 632. 
vesical disorders in, 633. 
nervous disorders in, 633. 
new mode of reduction in, 633. 
Guernsey's elevator in, 634. 
preparatory treatment for the re- 
duction of, 637. 
Rheumatism during pregnancy, 51. 
and menorrhagia, 263. 
a predisponent of chorea, 318. 
and neuralgia at the climacteric, 
505, 520, 
Rheumatic diathesis in ovarian neu- 
ralgia, 758. 
Rhus tox. in menstrual epilepsy, 174. 

in stomatitis materna, 351. 
Rouget, theory of metro-peritonitis, 
48. 



SALICYLATE of soda in pelvi- 

O peritonitis, 381. 
Salpingitis, 1019. 

varieties of, 1019. * 
Salpingotomy, 1028. , 

Battey-Tait operation, 1028. 
Surofulosis a predisponent of chronic 

cervical endo-metritis, 453. 
Secale in sub-involution, 359. 
Sepia in chlorosis, 110. 
Sequelae of abortion, 334. 

of pelviocellulitis, 397. 
Serre-fines in laceration of the perin- 
eum, 897. 
Sexual excesses and pelvic hsemato- 

cele, 419. 
Simon's manual exploration of the 
rectum, 80. 

method of cystotomy, 581. 
Sims' elevator in fibroids, 92. 
repositor in anti-flexion, 627. 
method for reducing inversion,, 

646. 
operation in epithelioma of the 
uterus, 718. 
for vaginismus, 853. 
Sound, the uterine, in diagnosis, 84. 
in diseases of the cervix, 84. 
to test the mobility of the uterus, 

85. 
in tumors of the uterus, 86. 
in deviations of the, organ, 86. 
mode of introduction of, 91. 
time for use of, 87. 
difficulty of introducing, 88. 



INDEX. 



1069 



Sound, choice of, 91. 

versus the tenaculum, 93. 

use of in obstructive dysmenor- 
rhea, 206. 
Spanemia in chlorosis, 103. 
Spasmodic dysmenorrhea in chlorosis 
111. 

adjuvants in, 111. 

dysmenorrhea, 215. 
Special pathology, importance of, 674. 
Speculum, the best uterine, 6y. 

Sims' 70. 

mode of passing the, 73. 

painless withdrawal of, 73. 

and sound conjoined, 90. 
Spinal irritation and hysteria, 793. 

notalgia, 815. 

causes of, 818. 

errors in the treatment of, 819. 

is of nervous origin, 820. 

exciting causes of, 820. 

symptoms of, 82U. 

and uterine disease, 822. 

reflex symptoms in, 822. 

from ovarian implication, 823. 

diagnosis of, 823. 

may arise from coccyodynia, 824. 

diagnosis of, from inflammation 
of the cord, 824. 

prognosis of, 825. 

treatment of, 825. 

in amenorrhea and at the climac- 
teric, 826. 

remedies for effects of the spinal 
injury in, 827. 

remedies for rheumatic and neu- 
ralgic symptoms in, 827. 

remedies for uterine and ovarian 
symptoms in, 827. 

local adjuvants for, 828. 

domestic expedients in, 828. 

faradization in, 829. 

prolapsus uteri, and laceration of 
the perineum, 830. 
Sponge tent in membranous dysmen- 
orrhea, 232. 

in dilating the urethra, 566. 

mode of applying, 567. 

in urethritis, 568. 

a practical hint in the use of, 568. 
Spontaneous discharge of a renal cal- 
culus, 587. 

cures of prolapsus uteri, 604. 
Stage of effusion in pelvi-peritonitis, 

370. 
Stem dilators in obstructive dysmen- 
orrhea, 208. 

pessaries in 2nte-flexion, 62S. 
Stenosis of the cervix in dysmenor- 
rhea, 201. 
Sterility from dysmenorrhea, 189. 



SteriMty, a sequel of membranous dys- 
menorrhea, 233. 

from menorrhagia, 259, 

from a profuse leucorrhea, 492, 
674. 

from ovaritis, 748. 
Stomatitis materna, 339. 

limited to gestation, 310. 

the peculiar lesion in, 340. 

incidental symptoms in. 341. 

a constitutional disease, 342. 

a local ulceration, 342. 

incidental gastric disorders of, 
343. 

causes of the digestive derange- 
ment in, 343. 

diarrhea a contingent of, 343. 

renal and vesical symptoms in, 
344. 

the anemia in, 344. 

date of onset, 345. 

diagnosis of, 345. 

prognosis of, 345. 

treatment of, 346. 

acidulated drinks in, 347. 

expedients for arresting, 347. 

weaning the child not specific in, 
348. 

may disappear with change of 
climate, 348. 

medical treatment for, 348. 

arsenicum alb. in, 349. 

mercurius in, 349. 

calcarea carb. in, 350. 

ammonium carb. in, 350. 

baryta carb. natrum mur. in, 350. 

veronica beccabunga in, 350. 

rhus tox. in, 351. 

local treatment of, 351. 
Stone in the bladder and urethra, 585. 

relative frequency of, in women, 
586. 

causes of, 586. 

prognosis in, 586. 

treatment or, 587. 

lithotripsy and vaginal cystot- 
omy for, 587. 

supra-pubic lithotomy for, 587. 

spontaneous discharg'e of, 587. 
Study, diagnosis, and pathology, 842. 

pathogenesis and symptomatol- 
ogy, 843. 
Sub-involution of the uterus, 353. 

depth of the uterus in, 355. 

various causes of, 355. 

negative symptoms in, 355. 

relation of post-partum haemor- 
rhage to, 356. 

treatment of, 357. 

prime indication for treatment of. 
357. 



1090 



INDEX. 



Sub-involution, physiological action 
of ergot in, 358. 
indication for secale in, 359. 

china, etc., in, 360. 
and recurrent abortion, 361. 
and chronic metritis of eighteen 

years' duration, 364. 
a source of disease, 58. 
and laceration of the cervix uteri, 

58, 862. 
and puerperal endo-metritis, 58. 
nursing a valuable prophylactic 
in, 61. 

cause of, 364. 

not always the result of in- 
flammation's, 
physical signs of, 365. 
chronic metritis, menorrhagia, 

and prolapsus, 365 
a practical lesson in the diagnosis 
of, 366. 
Sub-peritoneal fibroids, 1048 
Super-involution of the uterus, 121. 
Suppressed menstruation, 117. 

and retention not the same, 117, 
137. 
Suppression of the menses, hereditary 
tendency to, 118. 
incident to acute disease, 119. 
caused by change of climate, 119. 
from an idiosyncrasy, 119. 
from chronic disease, 119. 
essentially a glandular disease, 

120. 
ovario-pectoral sympathies in, 

120. 
super-involution of the uterus, 

cause of, 121. 
symptoms of, 121. 
derangement of nervous and vas- 
cular system in, 121. 
treatment of, 1^3. 
Surgery and therapeutics, 840. 
Surgical treatment of retention of the 
menses, 130. 
menorrhagia, 251. 
of pelvic hematocele, 435. 
of uterine cancer, 704. 
of vaginismus, 815. 
Sympathy between the generative 
organs and the heart, 98. 
uterine cervix and ovaries, 673. 
Symptoms, digestive, in chlorosis, 98. 
cerebral, in chlorosis, 98. 
cardiac, in chlorosis, 98. 
in amenorrhcea, 114. 
menstrual retention, 129. 
of uterine disorders may be re- 
motely located, 296. 
the effusion in pelvic cellulitis, 

389. 
versus disease, 608. 



Synonyms of pelvic cellulitis, 386. 
Syphilitic cachexia in menorrhagia, 

260. 
System, circulatory, in diseases of 
pregnancy, 50. 
nervous in, 50. 
digestive in, 50. 



TAPPING in pelvic hematocele, 
435. 
for diagnosis, 954. 
Tait's perineorrhaphy, 902. 

operation, 1028. 
Temperature and pulse in pelvi-peri- 

tonitis, 369. 
Terebinthma in pel vi - peritonitis, 

381. 
Therapeutics and surgery in diseases 

of women, 840. 
Thomas 1 operation for cystocele, 563. 

for inversion, 647. 
Three points in the local examination 

of pelviperitonitis, 370. 
Tilt's operation for vaginismus, 852. 
Totality of the symptoms, 135. 
"Touch" the rectal, 78. 
the recto-abdominal, 79. 
the vesical, 79. 
the vaginal, 79. 
applied to the bladder, 83. 
the vesico-vaginal and recto- ves- 
ical, 83. 
by the uterine sound, 84. 
in diagnosis, 84. 
Trachelorrhaphy in laceration of the 

cervix, 866. 
Traditional fallacy of parturition, 56. 
Traumatic lesions of parturition, 56. 
Treatment of pelvi-perironitis, 376. 
Tuberculous subjects most liable to 
pelvi-peritonitis, 376. 
diathesis and cervical endo-me- 
tritis, 454. 
Tuberculosis, pelvi-peritonitis and 

pelvic cellulitis, 405. 
Tumor the, in pelvi-peritonitis, 371. 
formation of, in pelvic cellulitis, 
388. 
Tympanites seldom lacking in pelvi- 
peritonitis, 369. 



ULCERATION sans inflammation. 
609. 
cause of abrasion, 609. 
of cervix with prolapsus, 605. 
of the womb, 649. 
Ulcer of the uterine cervix, 650. 
subjective symptoms of, 650. 
objective, local, 650. 
treatment for, 652. 



INDEX. 



1091 



Unilateral neuralgia from prolonged 

lactation, 496. 
Uraemia, apocynum in, 309. 
Urethra, dilatation of, 565. 
Urethral fiever and fissure of the 

urethra, 557. 
pathology of, 558. 
treatment for, 558. 
vesical and renal complications 

of, 559. 
may depend upon lacerations of 

the urethra, 559. 
Urethritis, non-specific, 551. 
causes of, 552. 
symptoms of, 553. 
character of the urine in, 553. 
diagnosis of, from stone, 554. 
from cystitis, 554. 
from gonorrhoea, 554. 
treatment of, 555. 
ihe urethral douche in, 556. 
Urinary organs, disorders of, in preg- 
nancy, 52. 
Uterine appendages, diseases of, 1016. 
women most subject to, 1016. 
from imperfect development, 1016. 
from acute dysmenorrhcea, 1016. 
from puerperal affections, 1017. 
from gonorrhceal infection, 1017. 
from membranous dysmenorrhcea, 

1018. 
from tubal and ovarian phthisis, 

1018. 
in scrofulous subjects, 1018. 
forms of ovarian degeneration, 

1019. 
varieties of salpingitis, 1019. 
subjective symptoms of, 1021. 
objective symptoms of, 1022. 
physical signs of, 1022. 
i confusing elements of diagnosis, 

1023. 
Explorative laparotomy in, 1023. 
the serious nature of, 1024. 
Battey's and Hegar's operation, 

1025. 
cases adapted for, 1025. 
indications for, 1025. 
in neuroses, 1026. 
in mania, 1027. 

recurrence of menstruation, 1027. 
Tait's operation, 1028. 
Battey-Tait operation, 1028. 
difficulties and dangers of, 1030. 
Uterine colic, 164. 

caused by vaginal injections, 164. 

symptoms of, 165. 

duration of, 165. 

incident to dysmenorrhcea, 165. 

incident to hysteria, 165. 

may precede menstruation, 166. ' 



Uterine colic frequent in intellectual 
women, 166. 
frequent in neuralgic women, 166. 
treatment for, 166. 
disorders not always easy of cure, 

263. 
fibroids, 1032, 1048, 1056. 
fibroids, menorrhagia from. 265. 
diagnosis of, from pelvic cel- 
lulitis, 396. 
diagnosis of, from hemato- 
cele, 428. 
diagnosis of, from ovarian 

dropsy, 940. 
diagnosis of, from uterine 
cancer, 696. 
cancer, diagnosis of, from syphi- 
litic ulceration, 697. 
epithelioma, 708. 
leucorrhoea, 451. 

souffle not diagnostic of pregnan- 
cy, 283, 907. 
cervix, stretching of the, in 

morning sickness, 308. 
surgery versus uterine therapeu- 
tics, 835. 
surgery, value of, 835. 

often followed by pelvic cel- 
lulitis, 396. 
therapeutics practically ignored, 

836. 
therapeutics ought not to be 

neglected, 838. 
cervix, irritable ulcer of, 658. 
laceration of, 855. 
and stomach, reflex relations 
of, 658. 
and vaginal catarrh from ovaritis, 

673. 
polypi, menorrhagia from, 274. 
polypi, diagnosis of, from cancer, 

696. 
polypi, 1064. 

common characteristics of, 

1065. 
diagnosis of, 1065. 
treatment of, 1086. 
recurrent fibrous, 1067. 
Uterine deviations and displace- 
ments, 5h9. 
ge eral considerations upon, 589. 
a clinical rule regarding, 590. 
causes of. are predisposing, avoid- 
able and exciting, 591. 
exciting causes of, three kinds, 

592. 
intrinsic causes of, 592. 
extrinsic causes of, 592. 
accidental causes of, 593. 
often cause of morning sickness 

of pregnancy, 305. 
symptoms of, 593. 



1092 



INDEX, 



Uterine deviations and displace- 
ments, diagnosis of, 593. 

general therapeutics of, 594. 

necessity for reliable indications 
of, 594, 

cardinal symptoms in, 595. 

opposition to pessaries in. an old 
story, 596. 

causes of mischief from pessaries 
in, 597. 

indications for pessaries in, 598. 

contra-indications for pessaries 
in, 5!;8. 

argument for pessaries in, 599, 

abdominal supporters in, 599, 600. 

with obstructive dysmenorrhcea, 
186.| 

may date from puberty, 604. 

and digestive disorders, 607. 
Utero-gastric and utero-cardiac de- 
rangements in hysteria, 809. 
Uterus, irregular development in, 46. 

twisting of the, during preg- 
nancy, 46. 

super-involution of, 121. 

retro- version of, from pelvic 
hematocele, 431. 

natural position of, 589. 

physiological changes in, 589. 

extirpation of, Freund's opera- 
tion for, 705. 

extirpation of, Lane's operation 
for, 706. 

extirpation of, Ormes' operation 
for, 707. 

fibro-cystic growths of, 901. 



VAGINAL palpation. 75. 
touch in ovaritis, 730. 
Vaginismus, 846. 

symptoms of, 847. 

local hyperesthesia a distinctive 

symptom of, 848. 
causes of, 849. 
diagnosis of, 850. 
medical treatment for, 850. 
surgical treatment for. 851. 
cured by excision of irritable tu- 
mors, 852. 
Dr. Tilts operation for, 852. 
Dr. Sims operation for, 853. 
other expedients for cure of, 854. 
Valerianate of zinc in ovarian neural- 
gia, 764. 
Varicose veins, 310. 
Variolus ovaritis, 744. 
Vascular tumor of the meatus urina- 
rius, 546. 
nature and location of, 547. 
necessity for physical examina- 
tion in, 548. 



Vascular tumor of the meatus urin- 
arius, symptoms of 547. 
obstacles to recovery from, 548. 
treatment for, 549. 
excision of, 549. 

a new mode of operating for, 549. 
after-treatment in, 550. 
Veratrum viride in dysmenorrhcea. 
215. 
in pelvic cellulitis, 411. 
in ovaritis, 752. 
Veronica bee. in stomatitis materna, 

350. 
Versions of the uterus, 631. 

compared with flexions, 631. 
the result of flexions, 631. 
retro— of the uterus, 632. 
Vesical lesions in pelvic cellulitis, 
404. 
inspection and palpation in dis- 
eases of the urethra, 568. 
value of, 569. 

a clinical caution concerning, 571. 
symptoms in ovaritis, 732. 
in prolapsus uteri, 602. 
Vesico - vaginal and recto - vesical 

touch, 83. 
Vesico-vaginal fistulse, 872. 
varieties of. 872. 
causes of, 873. 

its origin often in child-birth, 874. 
the pathognomonic signs of, 874. 
Dr. Holcombe's case of, 875. 
prognosis of, favorable, 877. 
treatment of, during lying-in, 878. 
in the post-puerperal cases, 

878. 
by cauterization, 878. 
special surgical indications for 

the operation in, 880. 
vivifying the margins of the 

wound in, 881. 
insertion of the sutures in, 882. 
vesical drainage after the opera- 
tion for, 885. 
removal of sutures in, 885. 
dangers of the operation for, 886. 
Electroplasty for, 886. 
Episiorrhaphy for, 887. 
Vicarious menstruation, 275. 
Vidal's operation for cystocele, 563. 
Voisin's description of the tumor in 

pelvic hematocele, 424. 
Vomiting, prolapsus uteri the excit- 
ing cause of, 134. 
relieved by repositing the uterus, 
134. 
Vulva, pruritus of the, 528. 
causes of, 528. 
eczema of the. 538. 
Vulvo- vaginal gland, abscess of, 534. 



INDEX. 



1093 



Vaginitis, 538. 

symptoms of, 540. 

the eruption in, 540. 

causes of, 541 . 

diagnosis of from granular vagin- 
itis, 541. 

follicular vulvitis, 541. 

treatment, topical and constitu- 
tional, 543. 



Vaginitis, prognosis in, 542. 

WEARING may be harmful, 61. 
necessary, 62. 
fashionable pretexts for, 475. 
proper time for, 476. 
White's manner of reducing inver- 
sion, 647. 
Womanhood 36. 

the clinical history of, 36, 38. 



